Provider Demographics
NPI:1639569825
Name:ARIZONA SKIN AND DERMATOLOGY PC
Entity type:Organization
Organization Name:ARIZONA SKIN AND DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANNTEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-529-4700
Mailing Address - Street 1:8380 W EMILE ZOLA AVE STE 5116
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4811
Mailing Address - Country:US
Mailing Address - Phone:602-529-4700
Mailing Address - Fax:602-529-4699
Practice Address - Street 1:153 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-4405
Practice Address - Country:US
Practice Address - Phone:602-529-4700
Practice Address - Fax:602-529-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ171303OtherPTAN