Provider Demographics
NPI:1770818130
Name:AZ DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:AZ DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSHRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-374-2462
Mailing Address - Street 1:1821 N TREKELL RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1705
Mailing Address - Country:US
Mailing Address - Phone:520-374-2462
Mailing Address - Fax:520-374-2467
Practice Address - Street 1:1025 W 24TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8366
Practice Address - Country:US
Practice Address - Phone:520-374-2462
Practice Address - Fax:520-374-2467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty