Provider Demographics
NPI:1073509402
Name:JENSEN, DOUGLAS P (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:JENSEN
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 52886
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2886
Mailing Address - Country:US
Mailing Address - Phone:602-298-7777
Mailing Address - Fax:623-930-6060
Practice Address - Street 1:5859 W TALAVI BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1869
Practice Address - Country:US
Practice Address - Phone:602-298-7777
Practice Address - Fax:623-930-6060
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11306207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ211681Medicaid
AZZ27797Medicare PIN
AZD37083Medicare UPIN