Healthcare Provider Details

I. General information

NPI: 1649776105
Provider Name (Legal Business Name): SUSAN DEL SORDI STAATS, DO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD STE 160
PHOENIX AZ
85028-3092
US

IV. Provider business mailing address

11209 N TATUM BLVD STE 160
PHOENIX AZ
85028-3092
US

V. Phone/Fax

Practice location:
  • Phone: 480-285-2180
  • Fax: 480-285-2182
Mailing address:
  • Phone: 480-285-2180
  • Fax: 480-285-2182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4490
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN DEL SORDI STAATS
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 480-285-2180