Healthcare Provider Details

I. General information

NPI: 1053823120
Provider Name (Legal Business Name): FIFE DERMATOLOGY UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E FOREMASTER DRIVE SUITE 260
ST.GEORGE UT
84790-4488
US

IV. Provider business mailing address

6460 MEDICAL CENTER ST STE 350
LAS VEGAS NV
89148-2423
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-5373
  • Fax: 702-673-5041
Mailing address:
  • Phone: 702-255-6647
  • Fax: 702-920-8444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS F FIFE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 702-255-6647