Basic Information
| Provider Information | |||||||||
| NPI: | 1790732832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD | ||||||||
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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: | 2224 W NORTHERN AVE | ||||||||
| Address2: | SUITE D-300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022771449 | ||||||||
| FaxNumber: | 6022779984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | SUPERFON | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6022771449 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.