Provider Demographics
NPI:1558767962
Name:ARIZONA SKIN AND DERMATOLOGY PC
Entity Type:Organization
Organization Name:ARIZONA SKIN AND DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANNTEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-815-8200
Mailing Address - Street 1:PO BOX 5002
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385-5002
Mailing Address - Country:US
Mailing Address - Phone:623-815-8200
Mailing Address - Fax:623-344-5458
Practice Address - Street 1:10249 W THUNDERBIRD BLVD
Practice Address - Street 2:SUIT 100
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3113
Practice Address - Country:US
Practice Address - Phone:623-815-8200
Practice Address - Fax:623-344-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty