1922378850 NPI number — INTEGRATED DERMATOLOGY OF MESA PLLC

Table of content: (NPI 1922378850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922378850 NPI number — INTEGRATED DERMATOLOGY OF MESA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED DERMATOLOGY OF MESA PLLC
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:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1922378850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 CLINT MOORE RD
Provider Second Line Business Mailing Address:
SUITE 226
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33487-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:
561-989-3665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 S 63RD ST
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-1620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-981-2888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTOPHER
Authorized Official First Name:
GERARD
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
561-314-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , 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)





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