Provider Demographics
NPI:1114991171
Name:BULLARO-ANDERER, DEANNA LYNN (DO)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:LYNN
Last Name:BULLARO-ANDERER
Suffix:
Gender:F
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:PO BOX 748860
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8860
Mailing Address - Country:US
Mailing Address - Phone:480-237-3040
Mailing Address - Fax:480-237-3049
Practice Address - Street 1:5304 E SOUTHERN AVE
Practice Address - Street 2:STE 110
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3623
Practice Address - Country:US
Practice Address - Phone:480-237-3040
Practice Address - Fax:480-237-3049
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3271207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
430653OtherAHCCCS
G70081Medicare UPIN
104000Medicare ID - Type Unspecified