Provider Demographics
NPI:1174521926
Name:SOUTHWEST SKIN SPECIALISTS LLC
Entity type:Organization
Organization Name:SOUTHWEST SKIN SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LUBER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:602-494-1817
Mailing Address - Street 1:10200 N 92ND ST
Mailing Address - Street 2:#205
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4534
Mailing Address - Country:US
Mailing Address - Phone:602-494-1817
Mailing Address - Fax:602-494-7103
Practice Address - Street 1:11130 N TATUM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1630
Practice Address - Country:US
Practice Address - Phone:602-494-1817
Practice Address - Fax:602-494-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ98010735207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBJQMedicare PIN