Provider Demographics
NPI:1902850597
Name:WEST DERMATOLOGY OF ARIZONA, INC
Entity Type:Organization
Organization Name:WEST DERMATOLOGY OF ARIZONA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WEST
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-335-8649
Mailing Address - Street 1:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0641
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-335-1994
Practice Address - Street 1:560 W BROWN RD
Practice Address - Street 2:SUITE 4001
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3221
Practice Address - Country:US
Practice Address - Phone:480-962-4269
Practice Address - Fax:480-962-3702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCS4930OtherRAILROAD MEDICARE
AZZ120557Medicare PIN
AZZ109457Medicare PIN