Healthcare Provider Details

I. General information

NPI: 1992966998
Provider Name (Legal Business Name): DIABETES AMERICA AZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W RAY RD SUITE 16
CHANDLER AZ
85224-3524
US

IV. Provider business mailing address

13171 MISTY WILLOW DR
HOUSTON TX
77070-5635
US

V. Phone/Fax

Practice location:
  • Phone: 480-855-6075
  • Fax: 480-855-6085
Mailing address:
  • Phone: 832-237-3500
  • Fax: 832-237-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: TINA JOHNSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 713-840-5245