Healthcare Provider Details

I. General information

NPI: 1780976985
Provider Name (Legal Business Name): BIRCH MARCEL DEGOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1860 AX HANDLE WAY
FLAGSTAFF AZ
86001-2857
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3366
  • Fax:
Mailing address:
  • Phone: 520-270-8139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number49071
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR72622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: