Healthcare Provider Details

I. General information

NPI: 1265456149
Provider Name (Legal Business Name): JONATHAN A MAITEM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DUNLAP AVE
PHOENIX AZ
85020-2825
US

IV. Provider business mailing address

2812 W PRINCEVILLE CT
ANTHEM AZ
85086-3001
US

V. Phone/Fax

Practice location:
  • Phone: 602-870-6060
  • Fax:
Mailing address:
  • Phone: 623-551-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3455
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: