Basic Information
| Provider Information | |||||||||
| NPI: | 1558395921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERKOTTE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | 375 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774161 | ||||||||
| FaxNumber: | 6022743394 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | 375 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774161 | ||||||||
| FaxNumber: | 6022743394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 9991 | AZ | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 9991 | AZ | X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 223553 | 05 | AZ | MEDICAID |