Healthcare Provider Details

I. General information

NPI: 1770921884
Provider Name (Legal Business Name): MARK S MAXWELL AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 N 64TH DR STE 201
GLENDALE AZ
85308-7109
US

IV. Provider business mailing address

9097 E DESERT COVE AVE STE 260
SCOTTSDALE AZ
85260-6279
US

V. Phone/Fax

Practice location:
  • Phone: 623-566-4718
  • Fax:
Mailing address:
  • Phone: 480-273-8510
  • Fax: 480-214-9933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberDA8304
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: