Healthcare Provider Details

I. General information

NPI: 1841360484
Provider Name (Legal Business Name): AARON RANDALL DEGROOT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W DEER VALLEY RD STE B106
PHOENIX AZ
85027
US

IV. Provider business mailing address

1515 W DEER VALLEY RD STE B106
PHOENIX AZ
85027-2041
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-4025
  • Fax: 602-391-2617
Mailing address:
  • Phone: 623-248-4025
  • Fax: 602-391-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4105
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number4105
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: