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General NPI Number Information
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NPI Number | 1063695252
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Entity Type | Organization
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Legal Business Name | ACTINODERMATOLOGY LTD
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 04/01/2010
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Provider Practice Location Address
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Address Line | 2600 E SOUTHERN AVE #A-2
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City | TEMPE
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State | AZ
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Zip | 85282-7610
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Country | US
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Telephone | 480-839-1767
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 E SOUTHERN AVE #A-2
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City | TEMPE
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State | AZ
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Zip | 85282-7610
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Country | US
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Telephone | 480-839-1767
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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. JERRY A PONITCH
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Credential | M.D.
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Telephone | 480-839-1767
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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 | 7979
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License Number State | AZ
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