Healthcare Provider Details

I. General information

NPI: 1710084488
Provider Name (Legal Business Name): CAROL JEAN ELNICKY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5351
  • Fax:
Mailing address:
  • Phone: 602-470-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56924
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01051127A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: