Provider Demographics
NPI:1578566139
Name:PACKER, JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:PACKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6622 N 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:3320 N 2ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-200-8288
Practice Address - Fax:602-200-8627
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2073207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249260Medicaid
NVDH066ZMedicare PIN
NVVWCGWMMedicare PIN
AZ112414Medicare PIN
AZ114940Medicare PIN
AZ71538Medicare PIN
AZ134448Medicare PIN
AZ134866Medicare PIN
AZZ123756Medicare PIN
C98287Medicare UPIN