Healthcare Provider Details

I. General information

NPI: 1487997763
Provider Name (Legal Business Name): EZEKIEL JOHN ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18205 N 51ST AVE STE 109
GLENDALE AZ
85308-1491
US

IV. Provider business mailing address

23363 N 61ST DR
GLENDALE AZ
85310-5736
US

V. Phone/Fax

Practice location:
  • Phone: 602-547-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number007195
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: