Provider Demographics
NPI:1497745350
Name:DESALVO, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:DESALVO
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 1:5601 W EUGIE AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1255
Mailing Address - Country:US
Mailing Address - Phone:602-978-1500
Mailing Address - Fax:602-978-0409
Practice Address - Street 1:5601 W EUGIE AVE
Practice Address - Street 2:STE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1255
Practice Address - Country:US
Practice Address - Phone:602-978-1500
Practice Address - Fax:602-978-0409
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ21631207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ137283Medicaid
MD21361Medicare ID - Type Unspecified
AZ137283Medicaid