Healthcare Provider Details

I. General information

NPI: 1982603494
Provider Name (Legal Business Name): JEFFREY P ROCKOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N RIM DR STE A
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

1330 N RIM DR STE A
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-7014
  • Fax: 928-779-3493
Mailing address:
  • Phone: 928-779-7014
  • Fax: 928-779-3493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number25161
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: