Basic Information
| Provider Information | |||||||||
| NPI: | 1487765319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERBER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EVAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 E CAMBRIDGE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850061462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029333277 | ||||||||
| FaxNumber: | 6029334326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/23/2019 | ||||||||
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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 | 207Y00000X | 036100171 | IL | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | 58195 | AZ | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 499847 | 05 | AZ | MEDICAID |