Healthcare Provider Details

I. General information

NPI: 1417775578
Provider Name (Legal Business Name): AZ MOBILE DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 E NORTHERN AVE STE 100
PHOENIX AZ
85020-3953
US

IV. Provider business mailing address

1825 E NORTHERN AVE STE 100
PHOENIX AZ
85020-3953
US

V. Phone/Fax

Practice location:
  • Phone: 623-680-9038
  • Fax: 602-805-5528
Mailing address:
  • Phone: 623-680-9038
  • Fax: 602-805-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: REVELINE GOROSPE
Title or Position: PRACTICE OWNER
Credential:
Phone: 623-680-9038