Basic Information
| Provider Information | |||||||||
| NPI: | 1568625077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINA | ||||||||
| FirstName: | LIDA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13400 E SHEA BLVD | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852595452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803018000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DR. | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 01067429A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 390200000X | 11012315 | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 51711 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.