Healthcare Provider Details

I. General information

NPI: 1558767962
Provider Name (Legal Business Name): ARIZONA SKIN AND DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10249 W THUNDERBIRD BLVD SUIT 100
SUN CITY AZ
85351-3113
US

IV. Provider business mailing address

PO BOX 5002
PEORIA AZ
85385-5002
US

V. Phone/Fax

Practice location:
  • Phone: 623-815-8200
  • Fax: 623-344-5458
Mailing address:
  • Phone: 623-815-8200
  • Fax: 623-344-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MANNTEJ SRA
Title or Position: OWNER
Credential: M.D.
Phone: 623-815-8200