Provider Demographics
NPI:1144569153
Name:ARIZONA HEART DOCTOR
Entity Type:Organization
Organization Name:ARIZONA HEART DOCTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-739-2014
Mailing Address - Street 1:PO BOX 32275
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85275-2275
Mailing Address - Country:US
Mailing Address - Phone:480-300-4646
Mailing Address - Fax:480-300-4647
Practice Address - Street 1:2045 S VINEYARD STE 119
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6889
Practice Address - Country:US
Practice Address - Phone:480-300-4646
Practice Address - Fax:480-300-4647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ609549Medicaid