Provider Demographics
NPI:1548806276
Name:ARIZONA MOBILE DERMATOLOGY AND WOUND CARE PLC
Entity Type:Organization
Organization Name:ARIZONA MOBILE DERMATOLOGY AND WOUND CARE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:SUPERFON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-417-8766
Mailing Address - Street 1:6535 N ARIZONA BILTMORE CIR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8907
Mailing Address - Country:US
Mailing Address - Phone:602-417-8766
Mailing Address - Fax:
Practice Address - Street 1:7301 E 2ND ST STE 200
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5610
Practice Address - Country:US
Practice Address - Phone:602-418-8766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0754OtherAZ MEDICAL LICENSE NUMBER
AZAS1261990OtherDEA #