Healthcare Provider Details

I. General information

NPI: 1922392398
Provider Name (Legal Business Name): SPECTRUM DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 07/21/2022
Certification Date: 01/24/2022
Deactivation Date: 12/22/2021
Reactivation Date: 01/24/2022

III. Provider practice location address

9500 E IRONWOOD SQUARE DR STE 110
SCOTTSDALE AZ
85258-4582
US

IV. Provider business mailing address

9500 E IRONWOOD SQUARE DR STE 110
SCOTTSDALE AZ
85258-4582
US

V. Phone/Fax

Practice location:
  • Phone: 480-948-8400
  • Fax: 480-948-8401
Mailing address:
  • Phone: 480-948-8400
  • Fax: 480-948-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number41487
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NANCY HAGEUNG KIM
Title or Position: OWNER
Credential: M.D.
Phone: 480-948-8400