=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396193843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERT PRINCESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2016
-----------------------------------------------------
Last Update Date | 04/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5133 N CENTRAL AVE 100
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-559-4776
-----------------------------------------------------
Fax | 866-526-7086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8711 E PINNACLE PEAK RD BOX 218
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-559-4776
-----------------------------------------------------
Fax | 866-526-7086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RICHARD DEMIR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-544-6900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 36773
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------