Healthcare Provider Details

I. General information

NPI: 1619378098
Provider Name (Legal Business Name): ARIZONA SKIN & DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 W BELL RD SUITE E103
GLENDALE AZ
85308-8529
US

IV. Provider business mailing address

8380 W EMILE ZOLA AVE SUITE 5116
PEORIA AZ
85381-4811
US

V. Phone/Fax

Practice location:
  • Phone: 602-529-4700
  • Fax: 602-529-4699
Mailing address:
  • Phone: 602-529-4700
  • Fax: 602-529-4699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MANNTEJ SRA
Title or Position: CEO
Credential: M.D.
Phone: 602-529-4700