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General NPI Number Information
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NPI Number | 1407129646
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Entity Type | Organization
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Legal Business Name | MYDOCKJ
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Dates
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Enumeration Date | 02/20/2012
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Last Update Date | 02/20/2012
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Provider Practice Location Address
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Address Line | 8520 E SHEA BLVD STE 105
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-6677
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Country | US
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Telephone | 602-390-1509
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Fax |
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Provider Business Mailing Address
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Address Line | 10105 E VIA LINDA STE 103-364
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5311
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Country | US
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Telephone | 602-390-1509
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KIM D JOHNSON
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Credential | MD
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Telephone | 602-390-1509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 19257
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License Number State | AZ
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