Basic Information
| Provider Information | |||||||||
| NPI: | 1467759274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARIZONA DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2224 W NORTHERN AVE | ||||||||
| Address2: | SUITE D-300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022771449 | ||||||||
| FaxNumber: | 6022779984 | ||||||||
| Practice Location | |||||||||
| Address1: | 10440 E RIGGS RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | SUN LAKES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852487751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808183314 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | SUPERFON | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6022772247 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARIZONA SKIN AND LASER THERAPY INSITUTE, LTD | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.