Healthcare Provider Details

I. General information

NPI: 1467471011
Provider Name (Legal Business Name): EVAN DUFFY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 W BROWN RD
MESA AZ
85201-3227
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 480-344-2007
  • Fax: 480-649-0783
Mailing address:
  • Phone: 602-470-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number31830
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier803652
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: