MEDICARE: DIABETES AMERICA AZ LLC

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992966998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETES AMERICA AZ LLC

Provider Business Mailing Address
First Line	:	13171 MISTY WILLOW DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-5635
Country	:	US
Telephone Number	:	832-237-3500
Fax Number	:	832-237-0200

Provider Business Practice Location Address
First Line	:	2875 W RAY RD
Second Line	:	SUITE 16
City	:	CHANDLER
State	:	AZ
Zip	:	85224-3524
Country	:	US
Telephone Number	:	480-855-6075
Fax Number	:	480-855-6085

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	TINA JOHNSON
Credential	:
Telephone Number	:	713-840-5245

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	08/08/2011

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Directions to “DIABETES AMERICA AZ LLC ” Practice Location

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