Basic Information
| Provider Information | |||||||||
| NPI: | 1497745350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESALVO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 W EUGIE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853041255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029781500 | ||||||||
| FaxNumber: | 6029780409 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 W EUGIE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853041255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029781500 | ||||||||
| FaxNumber: | 6029780409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 21631 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 137283 | 05 | AZ | MEDICAID |