Provider Demographics
NPI:1568648210
Name:DEER VALLEY OB-GYN LLC
Entity Type:Organization
Organization Name:DEER VALLEY OB-GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KISSIL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:608-395-0718
Mailing Address - Street 1:19636 N 27TH AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4013
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:1715 W NORTHERN AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5472
Practice Address - Country:US
Practice Address - Phone:602-395-0718
Practice Address - Fax:602-277-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3735207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120927Medicare PIN