Healthcare Provider Details

I. General information

NPI: 1972026896
Provider Name (Legal Business Name): PETER EBOT OBEN RVT, RDCS,RDMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 E MAIN ST STE 123
MESA AZ
85205-8928
US

IV. Provider business mailing address

6040 E MAIN ST STE 123
MESA AZ
85205-8928
US

V. Phone/Fax

Practice location:
  • Phone: 678-857-0705
  • Fax:
Mailing address:
  • Phone: 678-857-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number70271
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number70271
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number70271
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number70271
License Number StateAZ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: