Healthcare Provider Details

I. General information

NPI: 1790766533
Provider Name (Legal Business Name): MIKHAIL A BARGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15468 N CIVIC CENTER DR
SURPRISE AZ
85374
US

IV. Provider business mailing address

PO BOX 53568
PHOENIX AZ
85072-3568
US

V. Phone/Fax

Practice location:
  • Phone: 623-584-2917
  • Fax: 623-584-2945
Mailing address:
  • Phone: 623-544-5063
  • Fax: 623-544-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL9035
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32864
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: