Provider Demographics
NPI:1093787004
Name:FENZL, GREGORY J (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:FENZL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10835 N 25TH AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3458
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:19829 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4001
Practice Address - Country:US
Practice Address - Phone:623-879-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ857568Medicaid
AZ1Z7086OtherHEALTH NET OF ARIZONA
AZAZ0221810OtherBCBSAZ
AZ857568Medicaid
AZZ79427Medicare PIN
AZAZ0221810OtherBCBSAZ
AZZ25034Medicare PIN
AZZ79423Medicare PIN
AZZ121154Medicare PIN
AZZ121422Medicare UPIN
AZP00138635Medicare PIN