Healthcare Provider Details

I. General information

NPI: 1649274671
Provider Name (Legal Business Name): LEE P LARIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5056 N CENTRAL AVE
PHOENIX AZ
85012-1521
US

IV. Provider business mailing address

5056 N CENTRAL AVE
PHOENIX AZ
85012-1521
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-9111
  • Fax: 602-222-9333
Mailing address:
  • Phone: 602-222-9111
  • Fax: 602-222-9333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2459
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: