Basic Information
| Provider Information | |||||||||
| NPI: | 1548280530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13203 N 103RD AVENUE | ||||||||
| Address2: | SUITE C3 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239722116 | ||||||||
| FaxNumber: | 6239720521 | ||||||||
| Practice Location | |||||||||
| Address1: | 13203 N 103RD AVE | ||||||||
| Address2: | SUITE C3 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239722116 | ||||||||
| FaxNumber: | 6239720521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 174400000X | 10099 | AZ | Y | Other Service Providers | Specialist |
No ID Information.