=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669576948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN SAMUEL TRAIKOVICH D.O
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19636 N 27TH AVE STE 206
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85027-4015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-516-0930
-----------------------------------------------------
Fax | 623-580-9084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9967 E DESERT BEAUTY DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-2579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-317-9347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 3330
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------