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General NPI Number Information
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NPI Number | 1154318665
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Entity Type | Individual
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Provider Name | LAUREL RETAY DO
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Gender | Female
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Dates
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Enumeration Date | 09/29/2005
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 2055 E SOUTHERN AVE SUITE D
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City | TEMPE
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State | AZ
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Zip | 85282-7507
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Country | US
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Telephone | 480-345-7676
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Fax | 480-345-3560
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Provider Business Mailing Address
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Address Line | 105 S DELAWARE DR STE 2
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City | APACHE JUNCTION
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State | AZ
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Zip | 85120-6512
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Country | US
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Telephone | 480-646-1001
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Fax | 480-646-1002
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 3218
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License Number State | AZ
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