Basic Information
| Provider Information | |||||||||
| NPI: | 1922090992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORIS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | I. | ||||||||
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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: | 4131 N 24TH ST | ||||||||
| Address2: | B-102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029556632 | ||||||||
| FaxNumber: | 6023811341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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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 | 24281 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 358946 | 05 | AZ | MEDICAID |