MEDICARE: ARIZONA SKIN AND LASER THERAPY INSTITUTE, LLC

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		AZ

General Provider Information

NPI Number	:	1790732832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA SKIN AND LASER THERAPY INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	9900 N CENTRAL EXPY STE 500
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-0928
Country	:	US
Telephone Number	:	602-277-1449
Fax Number	:	602-277-9984

Provider Business Practice Location Address
First Line	:	2224 W NORTHERN AVE
Second Line	:	SUITE D-300
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4928
Country	:	US
Telephone Number	:	602-277-1449
Fax Number	:	602-277-9984

Authorized Official
Title or Position	:	MANAGING EMPLOYEE
Name	:	WILLIAM KO
Credential	:	MD
Telephone Number	:	602-277-1449

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	10/21/2025

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