Provider Demographics
NPI:1255684437
Name:ARIZONA STATE INTERNAL MEDICINE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:ARIZONA STATE INTERNAL MEDICINE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:GANGAN
Authorized Official - Last Name:JACINTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-361-8099
Mailing Address - Street 1:17100 N 67TH AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3605
Mailing Address - Country:US
Mailing Address - Phone:602-795-8698
Mailing Address - Fax:602-795-8699
Practice Address - Street 1:17100 N 67TH AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3605
Practice Address - Country:US
Practice Address - Phone:602-795-8698
Practice Address - Fax:602-795-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty