Healthcare Provider Details

I. General information

NPI: 1104856475
Provider Name (Legal Business Name): DOUGLAS L CUNNINGHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 N 19TH AVE SUITE 6
PHOENIX AZ
85015-4602
US

IV. Provider business mailing address

4350 N 19TH AVE SUITE 6
PHOENIX AZ
85015-4602
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-9191
  • Fax: 602-532-2973
Mailing address:
  • Phone: 602-264-9191
  • Fax: 602-532-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2325
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2325
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: