Basic Information
| Provider Information | |||||||||
| NPI: | 1215932850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATTON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 N 51ST AVE | ||||||||
| Address2: | STE 4 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238467575 | ||||||||
| FaxNumber: | 6232476386 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 N 51ST AVE | ||||||||
| Address2: | STE 4 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238467575 | ||||||||
| FaxNumber: | 6232476386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 23562 | AZ | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 23562 | AZ | X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | AZ0392760 | 01 | AZ | BCBS | OTHER | 339889 | 05 | AZ | MEDICAID | 85031A009 | 01 | AZ | TRICARE | OTHER | 1369849 | 01 | AZ | UNITED HEALTHCARE | OTHER | 1Z8749 | 01 | AZ | HEALTHNET | OTHER |