MEDICARE: DR. LETTY GUPIT TAN-FERMO M.D.

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	2084P0800X	Psychiatry Physician	28320	AZ

General Provider Information

NPI Number	:	1710097225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LETTY GUPIT TAN-FERMO M.D.

Provider Business Mailing Address
First Line	:	4747 N 7TH ST
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3653
Country	:	US
Telephone Number	:	602-279-7655
Fax Number	:	602-264-1806

Provider Business Practice Location Address
First Line	:	5701 W TALAVI BLVD
Second Line	:	SUITE 180
City	:	GLENDALE
State	:	AZ
Zip	:	85306-1886
Country	:	US
Telephone Number	:	623-486-8082
Fax Number	:	623-486-2739

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	02/16/2012

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