Healthcare Provider Details

I. General information

NPI: 1073829818
Provider Name (Legal Business Name): DAVID ELLIOTT MUDGE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E DUNLAP STE 105
PHOENIX AZ
85020
US

IV. Provider business mailing address

50 E. DUNLAP STE 105
PHOENIX AZ
85020
US

V. Phone/Fax

Practice location:
  • Phone: 602-944-4626
  • Fax: 602-944-2805
Mailing address:
  • Phone: 602-944-4626
  • Fax: 602-944-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3207
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: