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General NPI Number Information
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NPI Number | 1003082090
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Entity Type | Organization
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Legal Business Name | OMNI DERMATOLOGY INCORPORATED
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Dates
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Enumeration Date | 04/30/2008
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Last Update Date | 04/03/2024
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Provider Practice Location Address
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Address Line | 11851 N 51ST AVE STE E130
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City | GLENDALE
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State | AZ
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Zip | 85304-2843
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Country | US
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Telephone | 480-954-3919
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Fax | 480-954-3670
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Provider Business Mailing Address
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Address Line | 11851 N 51ST AVE STE E130
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City | GLENDALE
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State | AZ
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Zip | 85304-2843
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Country | US
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Telephone | 236-299-9540
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANDREW J RACETTE
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Credential | D.O.
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Telephone | 602-369-3634
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 4311
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License Number State | AZ
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