Healthcare Provider Details

I. General information

NPI: 1568648210
Provider Name (Legal Business Name): DEER VALLEY OB-GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 W NORTHERN AVE SUITE 108
PHOENIX AZ
85021-5472
US

IV. Provider business mailing address

19636 N 27TH AVE SUITE 303
PHOENIX AZ
85027-4013
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3735
License Number StateAZ

VIII. Authorized Official

Name: VICTOR KISSIL
Title or Position: PRESIDENT
Credential: DO
Phone: 608-395-0718