Healthcare Provider Details

I. General information

NPI: 1700102191
Provider Name (Legal Business Name): DR. DESIREE EKUNDAYO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESIREE EKUNDAYO

II. Dates (important events)

Enumeration Date: 04/11/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4633
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax: 602-262-8890
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036132039
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number60202
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number54470
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: