Provider Demographics
NPI:1922392398
Name:SPECTRUM DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:SPECTRUM DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:HAGEUNG
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-948-8400
Mailing Address - Street 1:9500 E IRONWOOD SQUARE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4582
Mailing Address - Country:US
Mailing Address - Phone:480-948-8400
Mailing Address - Fax:480-948-8401
Practice Address - Street 1:9500 E IRONWOOD SQUARE DR STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4582
Practice Address - Country:US
Practice Address - Phone:480-948-8400
Practice Address - Fax:480-948-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2022-07-21
Deactivation Date:2021-12-22
Deactivation Code:
Reactivation Date:2022-01-24
Provider Licenses
StateLicense IDTaxonomies
AZ41487207ND0101X
332900000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty