Healthcare Provider Details

I. General information

NPI: 1457416414
Provider Name (Legal Business Name): DESERT PAIN AND REHAB SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11047 N 19TH AVE
PHOENIX AZ
85029
US

IV. Provider business mailing address

11047 N 19TH AVE
PHOENIX AZ
85029-4816
US

V. Phone/Fax

Practice location:
  • Phone: 602-944-2222
  • Fax: 602-331-2499
Mailing address:
  • Phone: 602-944-2222
  • Fax: 602-331-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3984
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number11336
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HERBERT DONALD GOODMAN
Title or Position: CO-OWNER
Credential: M.D.
Phone: 602-944-2222