Provider Demographics
NPI:1063507929
Name:GIEDRAITIS, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:GIEDRAITIS
Suffix:
Gender:M
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:PO BOX 7133
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85216-7133
Mailing Address - Country:US
Mailing Address - Phone:480-985-1093
Mailing Address - Fax:
Practice Address - Street 1:6305 N MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-5313
Practice Address - Country:US
Practice Address - Phone:480-985-1093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9901208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ224832Medicaid
AZAZ0007450OtherBCBS
AZ2Z0566OtherHEALTHNET