MEDICARE: ARIZONA SKIN AND DERMATOLOGY PC

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	207R00000X	Internal Medicine Physician
2	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z171303	OTHER	AZ	PTAN

General Provider Information

NPI Number	:	1639569825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA SKIN AND DERMATOLOGY PC

Provider Business Mailing Address
First Line	:	8380 W EMILE ZOLA AVE STE 5116
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-4811
Country	:	US
Telephone Number	:	602-529-4700
Fax Number	:	602-529-4699

Provider Business Practice Location Address
First Line	:	153 W CENTRAL AVE
Second Line	:
City	:	COOLIDGE
State	:	AZ
Zip	:	85128-4405
Country	:	US
Telephone Number	:	602-529-4700
Fax Number	:	602-529-4699

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MANNTEJ SRA
Credential	:	M.D.
Telephone Number	:	602-529-4700

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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