Provider Demographics
NPI:1821896804
Name:INTEGRATIVE DERMATOLOGY PA CLINIC
Entity type:Organization
Organization Name:INTEGRATIVE DERMATOLOGY PA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:FEROZA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:941-840-1387
Mailing Address - Street 1:7533 S CENTER VIEW CT STE R
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-5526
Mailing Address - Country:US
Mailing Address - Phone:941-840-1387
Mailing Address - Fax:
Practice Address - Street 1:1110 ECHO PASS ST.
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052
Practice Address - Country:US
Practice Address - Phone:941-840-1387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care