Healthcare Provider Details

I. General information

NPI: 1740381920
Provider Name (Legal Business Name): ERIC VANCE HASTRITER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5779 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

5779 E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006-01503
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number43021
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: