Basic Information
| Provider Information | |||||||||
| NPI: | 1811320203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE CONSULTANTS OF ARIZONA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 S LINDSAY RD | ||||||||
| Address2: | STE 123 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852971503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179691281 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Practice Location | |||||||||
| Address1: | 19841 N 27TH AVE STE 403 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024390274 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALMUTI | ||||||||
| AuthorizedOfficialFirstName: | WALID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9179691281 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 35819 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 35819 | 01 | AZ | LICENSE | OTHER | 228441 | 05 | AZ | MEDICAID |