Healthcare Provider Details

I. General information

NPI: 1083841225
Provider Name (Legal Business Name): DANIEL PETERSON SKINNER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 W SOUTHERN AVE STE 102
MESA AZ
85202-4736
US

IV. Provider business mailing address

2250 W SOUTHERN AVE STE 102
MESA AZ
85202-4736
US

V. Phone/Fax

Practice location:
  • Phone: 480-835-5532
  • Fax: 480-962-0106
Mailing address:
  • Phone: 480-835-5532
  • Fax: 480-962-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number32259
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number48691
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number48691
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR71509
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2010010429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: