MEDICARE: DESERT SKY DERMATOLOGY, 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	207ND0900X	Dermatopathology Physician	45370	AZ
2	207NS0135X	Procedural Dermatology Physician	29461	AL
3	207N00000X	Dermatology Physician	45370	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871851691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT SKY DERMATOLOGY, PLLC

Provider Business Mailing Address
First Line	:	1688 E. BOSTON ST.
Second Line	:	SUITE #101
City	:	GILBERT
State	:	AZ
Zip	:	85295-6220
Country	:	US
Telephone Number	:	480-855-0085
Fax Number	:	480-855-0086

Provider Business Practice Location Address
First Line	:	1688 E. BOSTON ST.
Second Line	:	SUITE #101
City	:	GILBERT
State	:	AZ
Zip	:	85295-6220
Country	:	US
Telephone Number	:	480-855-0085
Fax Number	:	480-855-0086

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	CANDICE BERGER
Credential	:
Telephone Number	:	480-855-0085

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	03/07/2024

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