Provider Demographics
NPI:1528209889
Name:EAST VALLEY OB/GYN
Entity Type:Organization
Organization Name:EAST VALLEY OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-461-1161
Mailing Address - Street 1:1450 S DOBSON RD
Mailing Address - Street 2:STE. B221
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4712
Mailing Address - Country:US
Mailing Address - Phone:480-461-1161
Mailing Address - Fax:480-835-1482
Practice Address - Street 1:1450 S DOBSON RD
Practice Address - Street 2:STE. B221
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4712
Practice Address - Country:US
Practice Address - Phone:480-461-1161
Practice Address - Fax:480-835-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28517207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ522799Medicaid
AZ109112Medicare PIN
AZ522799Medicaid