Healthcare Provider Details

I. General information

NPI: 1851599724
Provider Name (Legal Business Name): KELLY L. KANTARTZIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY LYNN GERSCHULTZ MD

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 E PRESIDIO ST
MESA AZ
85215-1134
US

IV. Provider business mailing address

PO BOX 12127
BELFAST ME
04915-4012
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-5111
  • Fax: 480-834-5222
Mailing address:
  • Phone: 480-834-5111
  • Fax: 480-834-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number48877
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: