Provider Demographics
NPI:1659467397
Name:ARIZONA ASSOCIATES IN DERMATOLOGY AND COSMETIC SURGERY, LLC
Entity Type:Organization
Organization Name:ARIZONA ASSOCIATES IN DERMATOLOGY AND COSMETIC SURGERY, LLC
Other - Org Name:ARIZONA DERMATOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-5807
Mailing Address - Street 1:830 AINSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1630
Mailing Address - Country:US
Mailing Address - Phone:928-776-0325
Mailing Address - Fax:928-776-0405
Practice Address - Street 1:830 AINSWORTH DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1630
Practice Address - Country:US
Practice Address - Phone:928-776-0325
Practice Address - Fax:928-776-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29683207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
207N00000X, 207NI0002X
AZ48829208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103461Medicare UPIN
AZE76808Medicare UPIN
AZ103462Medicare ID - Type Unspecified
AZH52068Medicare UPIN
AZ103461Medicare PIN
AZ103463Medicare ID - Type Unspecified