Basic Information
| Provider Information | |||||||||
| NPI: | 1972892339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAWADROUS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 S VAL VISTA DR | ||||||||
| Address2: | STE 117-118 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852046401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 W GILA LN | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185986 | ||||||||
| FaxNumber: | 4804366582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 59910 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53748 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 256838 | 05 | AZ | MEDICAID |