Provider Demographics
NPI:1174855159
Name:JENSEN, DAVID LAURTIZ (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAURTIZ
Last Name:JENSEN
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 1:3090 N LITCHFIELD RD STE 120
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9214
Mailing Address - Country:US
Mailing Address - Phone:801-874-3135
Mailing Address - Fax:
Practice Address - Street 1:3090 N LITCHFIELD RD STE 120
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9214
Practice Address - Country:US
Practice Address - Phone:801-874-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9167838-8904207Q00000X
AZ005379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1174855159OtherNPI
AZ569756Medicaid