Provider Demographics
NPI:1306816517
Name:POPP, PHYLLIS I (DO)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:I
Last Name:POPP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6811 E SUPERSTITION SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4001
Mailing Address - Country:US
Mailing Address - Phone:480-641-4000
Mailing Address - Fax:
Practice Address - Street 1:6811 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4001
Practice Address - Country:US
Practice Address - Phone:480-641-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ356875Medicaid
AZ72892Medicare ID - Type Unspecified
AZ73883Medicare ID - Type Unspecified
AZ356875Medicaid
AZ72887Medicare ID - Type Unspecified
AZ72890Medicare ID - Type Unspecified
AZ72891Medicare ID - Type Unspecified
AZ72888Medicare ID - Type Unspecified
AZ72889Medicare ID - Type Unspecified
AZ73882Medicare ID - Type Unspecified