Healthcare Provider Details

I. General information

NPI: 1568755130
Provider Name (Legal Business Name): RANDY STEVEN GELOW II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 04/21/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD STE B185
PHOENIX AZ
85028-3091
US

IV. Provider business mailing address

11209 N TATUM BLVD STE 185
PHOENIX AZ
85028-6016
US

V. Phone/Fax

Practice location:
  • Phone: 602-669-2585
  • Fax: 602-669-2586
Mailing address:
  • Phone: 602-669-2585
  • Fax: 602-669-2586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49455
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number61-19507
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: