Healthcare Provider Details

I. General information

NPI: 1740481811
Provider Name (Legal Business Name): TAMARA MUSSO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10720 E SOUTHERN AVE SUITE 116
MESA AZ
85209-3810
US

IV. Provider business mailing address

10720 E SOUTHERN AVE SUITE 116
MESA AZ
85209-3810
US

V. Phone/Fax

Practice location:
  • Phone: 480-365-0050
  • Fax: 480-365-0049
Mailing address:
  • Phone: 480-365-0050
  • Fax: 480-365-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37012
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: