Provider Demographics
NPI:1821569138
Name:FIFE DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:FIFE DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-798-3008
Mailing Address - Street 1:6460 MEDICAL CENTER STREET STE 350
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2423
Mailing Address - Country:US
Mailing Address - Phone:702-255-6647
Mailing Address - Fax:702-933-1444
Practice Address - Street 1:1736 W. HORIZON RIDGE PARKWAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012
Practice Address - Country:US
Practice Address - Phone:702-255-6647
Practice Address - Fax:702-933-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-13
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty