Healthcare Provider Details

I. General information

NPI: 1518328871
Provider Name (Legal Business Name): GONDRA CENTER FOR REPRODUCTIVE CARE & ADVANCED GYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
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
PHOENIX AZ
85050-4265
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARIA GONDRA
Title or Position: MD/OWNER
Credential:
Phone: 402-490-5520