Healthcare Provider Details

I. General information

NPI: 1841929908
Provider Name (Legal Business Name): PRESCOTT MEDICAL AND DERMATOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 AINSWORTH DR
PRESCOTT AZ
86301-1612
US

IV. Provider business mailing address

810 AINSWORTH DR
PRESCOTT AZ
86301-1612
US

V. Phone/Fax

Practice location:
  • Phone: 928-515-1155
  • Fax: 928-460-5158
Mailing address:
  • Phone: 928-515-1155
  • Fax: 928-460-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BURT I FAIBISOFF
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 602-476-4074