Healthcare Provider Details

I. General information

NPI: 1376709741
Provider Name (Legal Business Name): MARIA MERCEDES GONDRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE B210
PHOENIX AZ
85050-4265
US

IV. Provider business mailing address

20940 N TATUM BLVD STE B210
PHOENIX AZ
85050-4265
US

V. Phone/Fax

Practice location:
  • Phone: 480-621-6203
  • Fax: 480-621-6203
Mailing address:
  • Phone: 480-621-6331
  • Fax: 480-621-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number44933
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: