Healthcare Provider Details

I. General information

NPI: 1689852105
Provider Name (Legal Business Name): ANTHONY MICHAEL DIGEORGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 E MAIN ST 103
MESA AZ
85203-8947
US

IV. Provider business mailing address

1345 E MAIN ST 103
MESA AZ
85203-8947
US

V. Phone/Fax

Practice location:
  • Phone: 480-223-0290
  • Fax: 480-223-0295
Mailing address:
  • Phone: 480-223-0290
  • Fax: 480-223-0295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16947
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number16947
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: