Provider Demographics
NPI:1033118393
Name:GONSALVES-WETHERELL, KAREN PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:PATRICIA
Last Name:GONSALVES-WETHERELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 W THUNDERBIRD RD
Mailing Address - Street 2:F1
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4636
Mailing Address - Country:US
Mailing Address - Phone:602-938-6960
Mailing Address - Fax:602-938-6069
Practice Address - Street 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:F1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-938-6960
Practice Address - Fax:602-938-6069
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27241208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCGBRMedicare PIN
AZCD5921Medicare PIN