Provider Demographics
NPI:1558321067
Name:CONDON, ETHEL FELICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHEL
Middle Name:FELICIA
Last Name:CONDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ETHEL
Other - Middle Name:F
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1801 E. VICO BELLA LUNA
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737
Mailing Address - Country:US
Mailing Address - Phone:515-205-2140
Mailing Address - Fax:515-699-5511
Practice Address - Street 1:3601 SOUTH 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723
Practice Address - Country:US
Practice Address - Phone:520-729-1450
Practice Address - Fax:520-629-4976
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29386207R00000X
MA236377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0172312Medicaid
IA1558321067Medicaid
MA2164787Medicaid
G69199Medicare UPIN
IA0172312Medicaid
IA1558321067Medicaid
IA719260380Medicare PIN
IA110176702Medicare PIN