Healthcare Provider Details

I. General information

NPI: 1174521926
Provider Name (Legal Business Name): SOUTHWEST SKIN SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 N TATUM BLVD SUITE 100
PHOENIX AZ
85028-1630
US

IV. Provider business mailing address

10200 N 92ND ST #205
SCOTTSDALE AZ
85258-4534
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-1817
  • Fax: 602-494-7103
Mailing address:
  • Phone: 602-494-1817
  • Fax: 602-494-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number98010735
License Number StateAZ

VIII. Authorized Official

Name: DR. HOWARD JAY LUBER
Title or Position: PRESIDENT
Credential: M. D.
Phone: 602-494-1817