Basic Information
| Provider Information | |||||||||
| NPI: | 1477828465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEAN | ||||||||
| FirstName: | MARIE RAPHAELLE | ||||||||
| MiddleName: | MONA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | BANNER UNIVERSITY MEDICAL CENTER | ||||||||
| Address2: | PO BOX 245073 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206265959 | ||||||||
| FaxNumber: | 5206264141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 N CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206265959 | ||||||||
| FaxNumber: | 5206264141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2012 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD449257 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 55190 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | 55190 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0206X | 35.123182 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.