Basic Information
Provider Information | |||||||||
NPI: | 1972572832 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HESS | ||||||||
FirstName: | IVIA | ||||||||
MiddleName: | ITSA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LANDRO | ||||||||
OtherFirstName: | IVIA | ||||||||
OtherMiddleName: | ITSA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6301 S MCCLINTOCK DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | TEMPE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852833393 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4802142300 | ||||||||
FaxNumber: | 4802142301 | ||||||||
Practice Location | |||||||||
Address1: | 2550 E GUADALUPE RD STE 115 | ||||||||
Address2: |   | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852345114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806321544 | ||||||||
FaxNumber: | 4806321533 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 05/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 24191 | AZ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 360157 | 01 | AZ | AHCCCS ID NUMBER | OTHER |