Healthcare Provider Details

I. General information

NPI: 1730163726
Provider Name (Legal Business Name): MICHAEL J DEPASO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10120 E OLD VAIL RD STE 100
TUCSON AZ
85747-9414
US

IV. Provider business mailing address

10120 E OLD VAIL RD STE 100
TUCSON AZ
85747-9414
US

V. Phone/Fax

Practice location:
  • Phone: 520-989-8012
  • Fax: 520-989-8014
Mailing address:
  • Phone: 520-989-8012
  • Fax: 520-989-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32011
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: