Healthcare Provider Details

I. General information

NPI: 1568029957
Provider Name (Legal Business Name): PROVIDENCE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N GATEWAY DR STE 100
PROVIDENCE UT
84332-9860
US

IV. Provider business mailing address

169 N GATEWAY DR STE 100
PROVIDENCE UT
84332-9860
US

V. Phone/Fax

Practice location:
  • Phone: 541-999-4475
  • Fax:
Mailing address:
  • Phone: 435-554-1182
  • Fax: 435-554-1950

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: TRAVIS S JAMES
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 435-554-1182