Provider Demographics
NPI:1407964463
Name:DARRELL D WADAS MD PC
Entity Type:Organization
Organization Name:DARRELL D WADAS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WADAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-254-6686
Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:#603
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2850
Mailing Address - Country:US
Mailing Address - Phone:602-254-6686
Mailing Address - Fax:602-254-4258
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:#603
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2850
Practice Address - Country:US
Practice Address - Phone:602-254-6686
Practice Address - Fax:602-254-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13563207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ275215Medicaid
AZZ111980Medicare PIN
AZ275215Medicaid