Healthcare Provider Details

I. General information

NPI: 1801014378
Provider Name (Legal Business Name): JOHN FORREST PRATER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 E SHEA BLVD STE 220
PHOENIX AZ
85028-3209
US

IV. Provider business mailing address

3101 E SHEA BLVD STE 220
PHOENIX AZ
85028-3209
US

V. Phone/Fax

Practice location:
  • Phone: 602-795-1834
  • Fax: 602-795-2608
Mailing address:
  • Phone: 602-795-1834
  • Fax: 602-795-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberOS4879
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number007409
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: