Basic Information
| Provider Information | |||||||||
| NPI: | 1710198783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARICOPA OBGYN | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 E CAMELBACK RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022411674 | ||||||||
| FaxNumber: | 6022307982 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 E CAMELBACK RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022411674 | ||||||||
| FaxNumber: | 6022307982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TRACIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HIPAA OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6235510192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.