Healthcare Provider Details

I. General information

NPI: 1366622466
Provider Name (Legal Business Name): JONATHAN DAVID TAIT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7790 N ORACLE RD STE 150 SUITE 150
ORO VALLEY AZ
85704-6589
US

IV. Provider business mailing address

7790 N ORACLE RD STE 150 SUITE 150
ORO VALLEY AZ
85704-6589
US

V. Phone/Fax

Practice location:
  • Phone: 520-777-9385
  • Fax: 520-306-4843
Mailing address:
  • Phone: 520-777-9385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number005503
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number005503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: