Healthcare Provider Details

I. General information

NPI: 1841073723
Provider Name (Legal Business Name): GOODMAN DERMATOLOGY AND MOHS SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 02/11/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13830 W CAMINO DEL SOL STE 240
SUN CITY WEST AZ
85375-4746
US

IV. Provider business mailing address

13830 W CAMINO DEL SOL STE 240
SUN CITY WEST AZ
85375-4746
US

V. Phone/Fax

Practice location:
  • Phone: 714-955-1214
  • Fax:
Mailing address:
  • Phone: 714-955-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE BOGDAN
Title or Position: BILLING SPECIALIST
Credential:
Phone: 484-359-8909