MEDICARE: DOUGLAS L CUNNINGHAM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	2325	AZ
2	207Q00000X	Family Medicine Physician	2325	AZ

General Provider Information

NPI Number	:	1104856475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS L CUNNINGHAM D.O.

Provider Business Mailing Address
First Line	:	4350 N 19TH AVE
Second Line	:	SUITE 6
City	:	PHOENIX
State	:	AZ
Zip	:	85015-4602
Country	:	US
Telephone Number	:	602-264-9191
Fax Number	:	602-532-2973

Provider Business Practice Location Address
First Line	:	4350 N 19TH AVE
Second Line	:	SUITE 6
City	:	PHOENIX
State	:	AZ
Zip	:	85015-4602
Country	:	US
Telephone Number	:	602-264-9191
Fax Number	:	602-532-2973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	04/13/2021

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