Provider Demographics
NPI:1255599577
Name:DESERT DERMATOLOGY LLC
Entity type:Organization
Organization Name:DESERT DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:LEPOSAVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-233-4569
Mailing Address - Street 1:9167 W FLAMINGO RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6472
Mailing Address - Country:US
Mailing Address - Phone:702-233-4569
Mailing Address - Fax:702-255-3223
Practice Address - Street 1:9167 W FLAMINGO RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-6472
Practice Address - Country:US
Practice Address - Phone:702-233-4569
Practice Address - Fax:702-255-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV101544Medicare UPIN