Provider Demographics
NPI:1134165657
Name:ARIZONA SKIN SPECIALISTS PLLC
Entity type:Organization
Organization Name:ARIZONA SKIN SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-482-1300
Mailing Address - Street 1:16620 N 40TH ST
Mailing Address - Street 2:STE I-5
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3348
Mailing Address - Country:US
Mailing Address - Phone:602-482-1300
Mailing Address - Fax:
Practice Address - Street 1:16620 N 40TH ST
Practice Address - Street 2:STE I-5
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3348
Practice Address - Country:US
Practice Address - Phone:602-482-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24917207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK3265OtherMEDICAL LICENSE
TNMD0000031574OtherMEDICAL LICENSE