Healthcare Provider Details

I. General information

NPI: 1417673112
Provider Name (Legal Business Name): DESERT DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 E TANGERINE RD STE 161
ORO VALLEY AZ
85755-6217
US

IV. Provider business mailing address

2551 E CALLE SIN RUIDO
TUCSON AZ
85718-7337
US

V. Phone/Fax

Practice location:
  • Phone: 520-771-0288
  • Fax: 520-771-0289
Mailing address:
  • Phone: 269-370-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE GOEDKEN
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 269-370-0510