Basic Information
Provider Information | |||||||||
NPI: | 1063573079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOOD HEALTH MEDICAL, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MY DR NOW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 261 N ROOSEVELT AVE | ||||||||
Address2: |   | ||||||||
City: | CHANDLER | ||||||||
State: | AZ | ||||||||
PostalCode: | 852262616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4803052888 | ||||||||
FaxNumber: | 4803052889 | ||||||||
Practice Location | |||||||||
Address1: | 287 E HUNT HWY | ||||||||
Address2: | SUITE 105 | ||||||||
City: | SAN TAN VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 851435096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806778282 | ||||||||
FaxNumber: | 4805350962 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 04/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZAMANI | ||||||||
AuthorizedOfficialFirstName: | PAYAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4803052888 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34305 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1063573079 | 01 | AZ | MEDICARE- NPI | OTHER | 6035350001 | 01 | AZ | MEDICARE NSC / DME | OTHER | 367745 | 05 | AZ |   | MEDICAID |