Healthcare Provider Details

I. General information

NPI: 1861477697
Provider Name (Legal Business Name): DIANE MARIE SHUCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W BELL RD
PHOENIX AZ
85023
US

IV. Provider business mailing address

25500 N. NORTERRA PARKWAY BLDG. B
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 602-588-3800
  • Fax: 602-588-3764
Mailing address:
  • Phone: 602-588-3800
  • Fax: 602-588-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33158
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: