Healthcare Provider Details

I. General information

NPI: 1922090992
Provider Name (Legal Business Name): JACQUELINE I. DORIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 N 24TH ST B-102
PHOENIX AZ
85016-6262
US

IV. Provider business mailing address

2500 W UTOPIA RD STE. 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-6632
  • Fax: 602-381-1341
Mailing address:
  • Phone: 602-214-6148
  • Fax: 602-214-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24281
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: