Provider Demographics
NPI:1013035211
Name:JUDY M PINSONNEAULT, D.O., P.C.
Entity Type:Organization
Organization Name:JUDY M PINSONNEAULT, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-629-5287
Mailing Address - Street 1:6106 E BROWN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4954
Mailing Address - Country:US
Mailing Address - Phone:480-641-4646
Mailing Address - Fax:480-641-2270
Practice Address - Street 1:6106 E BROWN RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4954
Practice Address - Country:US
Practice Address - Phone:480-641-4646
Practice Address - Fax:480-641-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
60137Medicare ID - Type Unspecified