MEDICARE: ARIZONA SKIN SPECIALISTS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	24917	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K3265	OTHER	TX	MEDICAL LICENSE
2	MD0000031574	OTHER	TN	MEDICAL LICENSE

General Provider Information

NPI Number	:	1134165657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA SKIN SPECIALISTS PLLC

Provider Business Mailing Address
First Line	:	16620 N 40TH ST
Second Line	:	STE I-5
City	:	PHOENIX
State	:	AZ
Zip	:	85032-3348
Country	:	US
Telephone Number	:	602-482-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	16620 N 40TH ST
Second Line	:	STE I-5
City	:	PHOENIX
State	:	AZ
Zip	:	85032-3348
Country	:	US
Telephone Number	:	602-482-1300
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARK E. B. JOHNSON
Credential	:	MD
Telephone Number	:	602-482-1300

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	04/26/2011

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Directions to “ARIZONA SKIN SPECIALISTS PLLC ” Practice Location

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