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General NPI Number Information
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NPI Number | 1770818130
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Entity Type | Organization
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Legal Business Name | AZ DERMATOLOGY, LLC
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Dates
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Enumeration Date | 10/02/2009
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Last Update Date | 12/07/2017
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Provider Practice Location Address
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Address Line | 1025 W 24TH ST SUITE 5
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City | YUMA
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State | AZ
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Zip | 85364-8366
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Country | US
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Telephone | 520-374-2462
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Fax | 520-374-2467
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Provider Business Mailing Address
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Address Line | 1821 N TREKELL RD SUITE 5
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City | CASA GRANDE
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State | AZ
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Zip | 85122-1705
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Country | US
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Telephone | 520-374-2462
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Fax | 520-374-2467
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAYSHRI GAMOTH
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Credential | M.D.
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Telephone | 520-374-2462
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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 | 36353
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License Number State | AZ
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