Provider Demographics
NPI:1871851691
Name:DESERT SKY DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:DESERT SKY DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-855-0085
Mailing Address - Street 1:1688 E. BOSTON ST.
Mailing Address - Street 2:SUITE #101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6220
Mailing Address - Country:US
Mailing Address - Phone:480-855-0085
Mailing Address - Fax:480-855-0086
Practice Address - Street 1:1688 E. BOSTON ST.
Practice Address - Street 2:SUITE #101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6220
Practice Address - Country:US
Practice Address - Phone:480-855-0085
Practice Address - Fax:480-855-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45370207N00000X, 207ND0900X
AL29461207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ757618Medicaid
AL102I075127Medicare PIN