MEDICARE: DR. ALYSSA PABELLE DIPALAC VIVAS D.O.

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	207Q00000X	Family Medicine Physician	R2590	AZ
2	207Q00000X	Family Medicine Physician	007363	AZ

General Provider Information

NPI Number	:	1720460819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALYSSA PABELLE DIPALAC VIVAS D.O.

Provider Business Mailing Address
First Line	:	21212 E OCOTILLO RD
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-9667
Country	:	US
Telephone Number	:	602-755-0800
Fax Number	:	480-571-7973

Provider Business Practice Location Address
First Line	:	21212 E OCOTILLO RD
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-9667
Country	:	US
Telephone Number	:	602-755-0800
Fax Number	:	480-571-7973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	12/02/2022

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