Provider Demographics
NPI:1164412466
Name:GHATTAS, EDWARD G (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:G
Last Name:GHATTAS
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 1:26900 N LAKE PLEASANT PKWY # 200
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1394
Mailing Address - Country:US
Mailing Address - Phone:623-561-3000
Mailing Address - Fax:623-561-3009
Practice Address - Street 1:26900 N LAKE PLEASANT PKWY # 200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1394
Practice Address - Country:US
Practice Address - Phone:623-561-3000
Practice Address - Fax:623-561-3009
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005164207Q00000X
MI5101011159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF78381OtherHEALTH ALLIANCE PLAN
MI080093523OtherMETRAHEALTH
AZ425169Medicaid
MI080D410020OtherBLUE CROSS BLUE SHIELD
MI0852524385OtherHEALTH PLUS
MI5895095OtherAETNA
MIF78381OtherHEALTH NET FEDERAL
MI080D410020OtherBLUE CARE NETWORK
MI204373OtherHEALTH ADVANTAGE NETWORK
MI3327505Medicaid
MIC2472OtherMCARE
MI204373OtherMCLAREN HEALTH PLAN
MI2341129003OtherCIGNA
MIF78381OtherHEALTH ALLIANCE PLAN
MI0M28430Medicare ID - Type Unspecified
MI5895095OtherAETNA
MI0M28430052Medicare ID - Type Unspecified