Healthcare Provider Details

I. General information

NPI: 1689925711
Provider Name (Legal Business Name): DEAN D ETTINGER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CALLE PORTAL SUITE 200
SIERRA VISTA AZ
85635-2900
US

IV. Provider business mailing address

155 CALLE PORTAL SUITE 200
SIERRA VISTA AZ
85635-2900
US

V. Phone/Fax

Practice location:
  • Phone: 520-458-0660
  • Fax: 520-458-9550
Mailing address:
  • Phone: 520-458-0660
  • Fax: 520-458-9550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number12142
License Number StateAZ

VIII. Authorized Official

Name: DR. DEAN D ETTINGER
Title or Position: OWNER
Credential: M.D.
Phone: 520-458-0660