Provider Demographics
NPI:1235391889
Name:BINGHAM, JEREMY K (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:K
Last Name:BINGHAM
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 1:2855 E BROWN RD STE 28
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4217
Mailing Address - Country:US
Mailing Address - Phone:480-625-4538
Mailing Address - Fax:
Practice Address - Street 1:2855 E BROWN RD STE 28
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-4217
Practice Address - Country:US
Practice Address - Phone:480-625-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5198207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ159843Medicare PIN