Healthcare Provider Details

I. General information

NPI: 1548596422
Provider Name (Legal Business Name): THEODORE CLYDE CARNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 N 32ND ST
PHOENIX AZ
85032
US

IV. Provider business mailing address

12251 N. 32ND ST
PHOENIX AZ
85032
US

V. Phone/Fax

Practice location:
  • Phone: 602-971-0950
  • Fax:
Mailing address:
  • Phone: 602-971-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20564
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number20564
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: