Provider Demographics
NPI:1619492378
Name:FIFE DERMATOLOGY, PC 1
Entity type:Organization
Organization Name:FIFE DERMATOLOGY, PC 1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FIFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-255-6647
Mailing Address - Street 1:10080 WEST ALTA DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-8651
Mailing Address - Country:US
Mailing Address - Phone:702-255-6647
Mailing Address - Fax:702-933-1444
Practice Address - Street 1:10080 WEST ALTA DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8651
Practice Address - Country:US
Practice Address - Phone:702-255-6647
Practice Address - Fax:702-933-1444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIFE DERMATOLOGY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty