Basic Information
| Provider Information | |||||||||
| NPI: | 1649255449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONDLE | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 E CAMELBACK RD | ||||||||
| Address2: | STE. 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649100 | ||||||||
| FaxNumber: | 6022649101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026877468 | ||||||||
| FaxNumber: | 6026877683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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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 | 207ZP0102X | 86942 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | ME94604 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | DR42367 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 35979 | AZ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 317047 | 01 | AZ | GROUP MEDICAID NUMBER | OTHER | 120390 | 01 | AZ | GROUP MEDICARE NUMBER | OTHER |