Provider Demographics
NPI:1881235489
Name:SOUTHWEST MOBILE DERMATOLOGY PLC
Entity type:Organization
Organization Name:SOUTHWEST MOBILE DERMATOLOGY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STATHAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-672-3675
Mailing Address - Street 1:11034 N 23RD DR # 105B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4743
Mailing Address - Country:US
Mailing Address - Phone:480-330-5840
Mailing Address - Fax:
Practice Address - Street 1:11034 N 23RD DR # 105B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4743
Practice Address - Country:US
Practice Address - Phone:480-330-5840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty