Healthcare Provider Details

I. General information

NPI: 1558216093
Provider Name (Legal Business Name): WILLOW DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7544 N LA CHOLLA BLVD
TUCSON AZ
85741-2307
US

IV. Provider business mailing address

7544 N LA CHOLLA BLVD
TUCSON AZ
85741-2307
US

V. Phone/Fax

Practice location:
  • Phone: 520-261-5205
  • Fax:
Mailing address:
  • Phone: 520-261-5205
  • 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: MOHAMMAD FAZEL
Title or Position: MD/CO-OWNER
Credential: MD, PHARMD
Phone: 520-261-5205