1265415392 NPI number — DR. RANDEL C DAVIS DO

Table of content: DR. RANDEL C DAVIS DO (NPI 1265415392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265415392 NPI number — DR. RANDEL C DAVIS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
RANDEL
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265415392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15623 S 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85048-8632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-460-4525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 W BETHANY HOME RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-249-0212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2484 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AW1436 . This is a "HEALTHNET - GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 453051001 . This is a "GROUP HEALTH - GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 860373636 . This is a "HUMANA - GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0728670 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 078817 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3981220 . This is a "EVERCARE - GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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