Healthcare Provider Details

I. General information

NPI: 1073973558
Provider Name (Legal Business Name): GONDRA CENTER FOR IVF LABORATORIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE B210
PHOENIX AZ
85050-4265
US

IV. Provider business mailing address

20940 N TATUM BLVD STE B210
PHOENIX AZ
85050-4265
US

V. Phone/Fax

Practice location:
  • Phone: 480-621-6203
  • Fax: 480-621-6331
Mailing address:
  • Phone: 480-621-6203
  • Fax: 480-621-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number44933
License Number StateAZ

VIII. Authorized Official

Name: DR. MARIA M GONDRA
Title or Position: DOCTOR
Credential: M.D.
Phone: 480-240-8815