Healthcare Provider Details

I. General information

NPI: 1235124397
Provider Name (Legal Business Name): GILLES LACHANCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S PONDEROSA ST
PAYSON AZ
85541-5542
US

IV. Provider business mailing address

9250 N 3RD ST SUITE 4010
PHOENIX AZ
85020-2437
US

V. Phone/Fax

Practice location:
  • Phone: 928-474-5729
  • Fax: 928-472-8205
Mailing address:
  • Phone: 602-633-3848
  • Fax: 602-633-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number31601
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: