Provider Demographics
NPI:1205818614
Name:PAPPOE, TUTANKHAMEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:TUTANKHAMEN
Middle Name:A
Last Name:PAPPOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W SOUTHERN AVE
Mailing Address - Street 2:2
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5012
Mailing Address - Country:US
Mailing Address - Phone:480-844-3648
Mailing Address - Fax:480-844-9363
Practice Address - Street 1:650 W SOUTHERN AVE
Practice Address - Street 2:2
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5012
Practice Address - Country:US
Practice Address - Phone:480-844-3648
Practice Address - Fax:480-844-9363
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33084208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105283Medicare ID - Type Unspecified
AZI17731Medicare UPIN