Provider Demographics
NPI:1235124397
Name:LACHANCE, GILLES (MD)
Entity Type:Individual
Prefix:
First Name:GILLES
Middle Name:
Last Name:LACHANCE
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 1:9250 N 3RD ST
Mailing Address - Street 2:SUITE 4010
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2437
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:807 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5542
Practice Address - Country:US
Practice Address - Phone:928-474-5729
Practice Address - Fax:928-472-8205
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ316012085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ779316Medicaid
AZ779316OtherAHCCCS
AZ779316OtherAHCCCS
AZ779316Medicaid
AZH84052Medicare UPIN