Provider Demographics
NPI:1003934977
Name:OLD PUEBLO DERMATOLOGY LTD
Entity type:Organization
Organization Name:OLD PUEBLO DERMATOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SOSNOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-742-7777
Mailing Address - Street 1:1980 W HOSPITAL DR
Mailing Address - Street 2:#307
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7802
Mailing Address - Country:US
Mailing Address - Phone:520-742-7777
Mailing Address - Fax:520-742-9316
Practice Address - Street 1:1980 W HOSPITAL DR
Practice Address - Street 2:#307
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7802
Practice Address - Country:US
Practice Address - Phone:520-742-7777
Practice Address - Fax:520-742-9316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty