Provider Demographics
NPI:1033275938
Name:ACACIA FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:ACACIA FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTINEZ-AKSAMIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-323-3617
Mailing Address - Street 1:PO BOX 43130
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3130
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:3801 N CAMPBELL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1448
Practice Address - Country:US
Practice Address - Phone:520-732-3361
Practice Address - Fax:520-323-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25298261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG68242Medicare UPIN