Provider Demographics
NPI:1376862888
Name:DEBARTOLO, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:DEBARTOLO
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 1:600 S DOBSON RD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-1818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZXXXXXXXX207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine