Healthcare Provider Details

I. General information

NPI: 1225065436
Provider Name (Legal Business Name): DAVID W HOMER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DUNLAP AVE JOHN C LINCOLN HOSPITAL, ED
PHOENIX AZ
85020-1350
US

IV. Provider business mailing address

250 E DUNLAP AVE
PHOENIX AZ
85020-2825
US

V. Phone/Fax

Practice location:
  • Phone: 602-870-6353
  • Fax:
Mailing address:
  • Phone: 602-317-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2815
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101009929
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: