Healthcare Provider Details

I. General information

NPI: 1821806902
Provider Name (Legal Business Name): GEORGE O OPUDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 01/18/2025
Certification Date: 01/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 N LOS ALTOS DR
CHANDLER AZ
85224-2134
US

IV. Provider business mailing address

2105 N LOS ALTOS DR
CHANDLER AZ
85224-2134
US

V. Phone/Fax

Practice location:
  • Phone: 520-340-1891
  • Fax:
Mailing address:
  • Phone: 520-340-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberD1A50Z
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: