Healthcare Provider Details

I. General information

NPI: 1316331259
Provider Name (Legal Business Name): SUSAN PATRICIA ANDUAGA BOCANEGRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 E CAMELBACK RD STE 202
PHOENIX AZ
85018-2718
US

IV. Provider business mailing address

4200 E CAMELBACK RD STE 202
PHOENIX AZ
85018-2718
US

V. Phone/Fax

Practice location:
  • Phone: 602-229-2200
  • Fax: 602-744-3929
Mailing address:
  • Phone: 602-229-2200
  • Fax: 602-744-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58314
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58314
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: