Healthcare Provider Details

I. General information

NPI: 1598323362
Provider Name (Legal Business Name): FIFE DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 E FLAMINGO RD # 213
LAS VEGAS NV
89119-5190
US

IV. Provider business mailing address

2110 E FLAMINGO RD # 213
LAS VEGAS NV
89119-5190
US

V. Phone/Fax

Practice location:
  • Phone: 702-255-6647
  • Fax: 702-933-1444
Mailing address:
  • Phone: 702-255-6647
  • Fax: 702-933-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS JACKSON FIFE
Title or Position: PHYSICIAN
Credential: MD
Phone: 702-255-6647