Basic Information
| Provider Information | |||||||||
| NPI: | 1598737595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EELKEMA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10835 N 25TH AVE | ||||||||
| Address2: | STE 240 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850293458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 19829 N 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238795720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28986 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1Z7086 | 01 | AZ | HEALTH NET OF AZ | OTHER | 559213 | 05 | AZ | MEDICAID |