Provider Demographics
NPI:1407129646
Name:MYDOCKJ
Entity Type:Organization
Organization Name:MYDOCKJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-390-1509
Mailing Address - Street 1:10105 E VIA LINDA
Mailing Address - Street 2:STE 103-364
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5311
Mailing Address - Country:US
Mailing Address - Phone:602-390-1509
Mailing Address - Fax:
Practice Address - Street 1:8520 E SHEA BLVD
Practice Address - Street 2:STE 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6677
Practice Address - Country:US
Practice Address - Phone:602-390-1509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty