Healthcare Provider Details

I. General information

NPI: 1609858851
Provider Name (Legal Business Name): MARIO SKOBIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37100 N GANTZEL RD STE 201
SAN TAN VALLEY AZ
85140-7352
US

IV. Provider business mailing address

800 WEST AVE SOUTH
LACROSSE WI
54601
US

V. Phone/Fax

Practice location:
  • Phone: 480-394-4520
  • Fax: 480-394-4469
Mailing address:
  • Phone: 608-791-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number42199
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: