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General NPI Number Information
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NPI Number | 1881235489
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Entity Type | Organization
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Legal Business Name | SOUTHWEST MOBILE DERMATOLOGY PLC
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Dates
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Enumeration Date | 10/04/2019
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Last Update Date | 10/04/2019
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Provider Practice Location Address
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Address Line | 11034 N 23RD DR # 105B
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City | PHOENIX
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State | AZ
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Zip | 85029-4743
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Country | US
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Telephone | 480-330-5840
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Fax |
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Provider Business Mailing Address
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Address Line | 11034 N 23RD DR # 105B
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City | PHOENIX
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State | AZ
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Zip | 85029-4743
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Country | US
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Telephone | 480-330-5840
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN STATHAKIS
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Credential | DO
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Telephone | 602-672-3675
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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 |
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License Number State |
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