Healthcare Provider Details

I. General information

NPI: 1164098570
Provider Name (Legal Business Name): ELLIOT DUTTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W OSBORN RD
PHOENIX AZ
85019-4037
US

IV. Provider business mailing address

3501 W OSBORN RD
PHOENIX AZ
85019-4037
US

V. Phone/Fax

Practice location:
  • Phone: 602-272-7676
  • Fax:
Mailing address:
  • Phone: 480-251-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number8344
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8344
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: