Provider Demographics
NPI:1609185347
Name:SOUTHWEST SKIN SPECIALISTS, LLC
Entity Type:Organization
Organization Name:SOUTHWEST SKIN SPECIALISTS, LLC
Other - Org Name:SOUTHWEST SKIN SPECIALISTS, LTD /
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-494-1817
Mailing Address - Street 1:11130 N TATUM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1662
Mailing Address - Country:US
Mailing Address - Phone:602-494-1817
Mailing Address - Fax:602-494-7103
Practice Address - Street 1:5010 E SHEA BLVD STE 130
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4709
Practice Address - Country:US
Practice Address - Phone:602-494-1817
Practice Address - Fax:602-494-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ98010735291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWMBJQOtherMEDICARE ID
AZZWMBJQMedicare UPIN