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General NPI Number Information
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NPI Number | 1346420577
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY CENTER OF YUMA PLLC
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Dates
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Enumeration Date | 11/05/2007
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Last Update Date | 03/24/2009
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Provider Practice Location Address
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Address Line | 2270 S RIDGEVIEW DR STE 302
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City | YUMA
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State | AZ
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Zip | 85364
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Country | US
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Telephone | 928-783-0169
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Fax |
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Provider Business Mailing Address
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Address Line | 2270 S RIDGEVIEW DR STE 302
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City | YUMA
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State | AZ
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Zip | 85364
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Country | US
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Telephone | 928-783-0169
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARY ELLEN JOAN LUCHETTI
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Credential | M.D.
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Telephone | 928-329-4761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 044009
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 28963
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License Number State | AZ
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