Healthcare Provider Details

I. General information

NPI: 1235464231
Provider Name (Legal Business Name): AZ DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 W APACHE TRL
APACHE JUNCTION AZ
85120-3728
US

IV. Provider business mailing address

1821 N TREKELL RD SUITE
CASA GRANDE AZ
85122-1705
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-3337
  • Fax: 520-374-2467
Mailing address:
  • Phone: 520-374-2462
  • Fax: 520-374-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36353
License Number StateAZ

VIII. Authorized Official

Name: DR. JAYSHRI GAMOTH
Title or Position: OWNER
Credential: M.D.
Phone: 520-374-2462