Healthcare Provider Details

I. General information

NPI: 1871851691
Provider Name (Legal Business Name): DESERT SKY DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1688 E. BOSTON ST. SUITE #101
GILBERT AZ
85295-6220
US

IV. Provider business mailing address

1688 E. BOSTON ST. SUITE #101
GILBERT AZ
85295-6220
US

V. Phone/Fax

Practice location:
  • Phone: 480-855-0085
  • Fax: 480-855-0086
Mailing address:
  • Phone: 480-855-0085
  • Fax: 480-855-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number45370
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number29461
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number45370
License Number StateAZ

VIII. Authorized Official

Name: CANDICE BERGER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 480-855-0085