Basic Information
| Provider Information | |||||||||
| NPI: | 1922112135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANSONNENBERG | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 N CENTRAL AVE | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063729 | ||||||||
| FaxNumber: | 6027989412 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063430 | ||||||||
| FaxNumber: | 6024064058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2085R0202X | 32416 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 919376 | 05 | AZ | MEDICAID |