Healthcare Provider Details

I. General information

NPI: 1780667725
Provider Name (Legal Business Name): KENNETH J MISHARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054
US

IV. Provider business mailing address

5777 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 Code208M00000X
TaxonomyHospitalist Physician
License Number32703
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25611
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: