Provider Demographics
NPI:1588797179
Name:SAGUARO DERMATOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:SAGUARO DERMATOLOGY ASSOCIATES LLC
Other - Org Name:PAPILLON DERMATOLOGY P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-914-4274
Mailing Address - Street 1:PO BOX 61025
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1025
Mailing Address - Country:US
Mailing Address - Phone:480-681-3300
Mailing Address - Fax:480-897-0820
Practice Address - Street 1:2150 S DOBSON RD STE 1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6487
Practice Address - Country:US
Practice Address - Phone:480-820-9775
Practice Address - Fax:480-897-0820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ22038Medicare PIN