Healthcare Provider Details

I. General information

NPI: 1609291848
Provider Name (Legal Business Name): RICHARD LEE AVERITTE JR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19646 N 27TH AVE STE 305
PHOENIX AZ
85027-4017
US

IV. Provider business mailing address

20401 N 73RD ST STE 230
SCOTTSDALE AZ
85255-4107
US

V. Phone/Fax

Practice location:
  • Phone: 480-556-0446
  • Fax:
Mailing address:
  • Phone: 480-556-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40537
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number40537
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number40537
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number40537
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number40537
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number40537
License Number StateAZ

VIII. Authorized Official

Name: MARLIE AVERITTE
Title or Position: CFO
Credential:
Phone: 480-556-0446