Basic Information
| Provider Information | |||||||||
| NPI: | 1033164538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE MOUNTAIN DERMATOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 288 N IRONWOOD DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852203830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806714086 | ||||||||
| FaxNumber: | 4806714105 | ||||||||
| Practice Location | |||||||||
| Address1: | 288 N IRONWOOD DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852203830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806714086 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | BRUAL | ||||||||
| AuthorizedOfficialFirstName: | GERARDO | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4806714086 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 070013565 | 01 | AZ | RAIL ROAD MEDICARE | OTHER |