Healthcare Provider Details

I. General information

NPI: 1336320613
Provider Name (Legal Business Name): ASSOCIATED DESERT GASTROENTEROLOGISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S POWER RD # 102
MESA AZ
85206-5235
US

IV. Provider business mailing address

215 S POWER RD SUITE 102
MESA AZ
85206-5235
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-9005
  • Fax: 480-396-9974
Mailing address:
  • Phone: 480-985-9005
  • Fax: 480-396-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12854
License Number StateAZ

VIII. Authorized Official

Name: DR. PREM C KUMAR
Title or Position: OWNER
Credential: MD
Phone: 480-985-9005