MEDICARE: DIRECT2MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	3162	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3162	OTHER	AZ	STATE LICENSE

General Provider Information

NPI Number	:	1568942613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRECT2MD

Provider Business Mailing Address
First Line	:	5656 E ORANGE BLOSSOM LN STE 5
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-8139
Country	:	US
Telephone Number	:	602-601-7430
Fax Number	:

Provider Business Practice Location Address
First Line	:	5656 E ORANGE BLOSSOM LN STE 5
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-8139
Country	:	US
Telephone Number	:	602-601-7430
Fax Number	:	602-601-7428

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	ADELLA CORDOVA
Credential	:
Telephone Number	:	623-326-1055

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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Directions to “DIRECT2MD ” Practice Location

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