Provider Demographics
NPI:1982849691
Name:DONSKY BOGLE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:DONSKY BOGLE DERMATOLOGY LLC
Other - Org Name:GRAND CANYON DERMATOLOGY PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DONSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-985-1093
Mailing Address - Street 1:1150 N COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-2537
Mailing Address - Country:US
Mailing Address - Phone:480-985-1093
Mailing Address - Fax:
Practice Address - Street 1:1150 N COUNTRY CLUB DR
Practice Address - Street 2:SUITE 6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-2537
Practice Address - Country:US
Practice Address - Phone:480-985-1093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ127286Medicare PIN