Provider Demographics
NPI:1770519019
Name:ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD
Entity type:Organization
Organization Name:ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:P
Authorized Official - Last Name:SUPERFON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-277-1449
Mailing Address - Street 1:2224 W NORTHERN AVE
Mailing Address - Street 2:D 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4928
Mailing Address - Country:US
Mailing Address - Phone:602-277-1449
Mailing Address - Fax:602-277-9984
Practice Address - Street 1:4232 E CACTUS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7602
Practice Address - Country:US
Practice Address - Phone:602-996-3050
Practice Address - Fax:602-494-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCKJCMedicare PIN