1588797179 NPI number — SAGUARO DERMATOLOGY ASSOCIATES LLC

Table of content: (NPI 1588797179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588797179 NPI number — SAGUARO DERMATOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGUARO DERMATOLOGY ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588797179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61025
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85082-1025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-681-3300
Provider Business Mailing Address Fax Number:
480-897-0820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 S DOBSON RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85202-6487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-820-9775
Provider Business Practice Location Address Fax Number:
480-897-0820
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEWITT
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
602-914-4274

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  13111 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com