Healthcare Provider Details

I. General information

NPI: 1346758653
Provider Name (Legal Business Name): ARIZONA ENDOCRINOLOGY & DIABETES CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 01/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 N 79TH AVE STE C136
GLENDALE AZ
85308-8471
US

IV. Provider business mailing address

18301 N 79TH AVE STE C136
GLENDALE AZ
85308-8471
US

V. Phone/Fax

Practice location:
  • Phone: 623-466-3890
  • Fax:
Mailing address:
  • Phone: 623-466-3890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number41644
License Number StateAZ

VIII. Authorized Official

Name: ABDULLAH HANNA-MOUSSA
Title or Position: OWNER
Credential: MD
Phone: 623-466-3890