Healthcare Provider Details

I. General information

NPI: 1619492378
Provider Name (Legal Business Name): FIFE DERMATOLOGY, PC 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 WEST ALTA DRIVE SUITE 120
LAS VEGAS NV
89145-8651
US

IV. Provider business mailing address

10080 WEST ALTA DRIVE SUITE 120
LAS VEGAS NV
89145-8651
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 Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS J. FIFE
Title or Position: CEO
Credential: M.D.
Phone: 702-255-6647