Basic Information
| Provider Information | |||||||||
| NPI: | 1700874153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DWIVEDI | ||||||||
| FirstName: | GARGI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022146148 | ||||||||
| FaxNumber: | 6022146149 | ||||||||
| Practice Location | |||||||||
| Address1: | 18404 N TATUM BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850321510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029921900 | ||||||||
| FaxNumber: | 6024857450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33472 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7627675 | 01 | AZ | AETNA | OTHER | AZ0774830 | 01 | AZ | BLUE CROSS BLUE SHEILD | OTHER |