Provider Demographics
NPI:1922378850
Name:INTEGRATED DERMATOLOGY OF MESA PLLC
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF MESA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-314-2000
Mailing Address - Street 1:902 CLINT MOORE RD
Mailing Address - Street 2:SUITE 226
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2800
Mailing Address - Country:US
Mailing Address - Phone:561-314-2000
Mailing Address - Fax:561-989-3665
Practice Address - Street 1:130 S 63RD ST
Practice Address - Street 2:SUITE 114
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1620
Practice Address - Country:US
Practice Address - Phone:480-981-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty