Provider Demographics
NPI:1992754824
Name:TUCSON DERMATOLOGY LTD
Entity type:Organization
Organization Name:TUCSON DERMATOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF TUCSON DERMATOLOGY LTD
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:520-886-4199
Mailing Address - Street 1:6640 E CARONDELET DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2119
Mailing Address - Country:US
Mailing Address - Phone:520-886-4199
Mailing Address - Fax:520-886-3114
Practice Address - Street 1:6640 E CARONDELET DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-886-4199
Practice Address - Fax:520-886-3114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8592207N00000X
AZ6653207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCHGSMedicare PIN