Basic Information
| Provider Information | |||||||||
| NPI: | 1407964463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DARRELL D WADAS MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | #603 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022546686 | ||||||||
| FaxNumber: | 6022544258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | #603 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022546686 | ||||||||
| FaxNumber: | 6022544258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | WADAS | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6022546686 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 13563 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 275215 | 05 | AZ | MEDICAID |