Basic Information
| Provider Information | |||||||||
| NPI: | 1922484088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY OF ARIZONA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN STE 300 | ||||||||
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| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8817 E BELL RD STE 101 | ||||||||
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| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852601589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | CRANDALL | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9704846303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.