Healthcare Provider Details

I. General information

NPI: 1003856683
Provider Name (Legal Business Name): MICHAEL VAN OPEL R N F A
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 W NORTHERN AVE
PHOENIX AZ
85021-5472
US

IV. Provider business mailing address

PO BOX 39179
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberRN032563
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: