1194767228 NPI number — JOHN J DE BARROS MD

Table of content: JOHN J DE BARROS MD (NPI 1194767228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194767228 NPI number — JOHN J DE BARROS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE BARROS
Provider First Name:
JOHN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194767228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85274-0640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-485-8585
Provider Business Mailing Address Fax Number:
480-545-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4860 E BASELINE RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-4670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-485-8585
Provider Business Practice Location Address Fax Number:
480-545-2673
Provider Enumeration Date:
06/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  33625 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AZ0422490 . This is a "BCBS AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".