1639101629 NPI number — SUZANNE BENTZ DO

Table of content: SUZANNE BENTZ DO (NPI 1639101629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639101629 NPI number — SUZANNE BENTZ DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTZ
Provider First Name:
SUZANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1639101629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1635 N GREENFIELD RD
Provider Second Line Business Mailing Address:
#134
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85205-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-854-7123
Provider Business Mailing Address Fax Number:
480-854-7627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 N GREENFIELD RD
Provider Second Line Business Practice Location Address:
#134
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85205-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-854-7123
Provider Business Practice Location Address Fax Number:
480-854-7627
Provider Enumeration Date:
07/07/2006

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: 207Q00000X , with the licence number:  2866 , 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: 080134177 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 6044688 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 120947 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0390840 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 4656562 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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