Provider Demographics
NPI:1598788499
Name:MAMANI, DEMETRIO BERNABE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIO
Middle Name:BERNABE
Last Name:MAMANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7373 N SCOTTSDALE RD
Mailing Address - Street 2:BUILDING E- SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253
Mailing Address - Country:US
Mailing Address - Phone:480-941-1211
Mailing Address - Fax:623-478-1534
Practice Address - Street 1:5601 W EUGIE AVE STE 106
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1256
Practice Address - Country:US
Practice Address - Phone:602-978-6255
Practice Address - Fax:602-564-9286
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33878207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ969701Medicaid
AZ969701Medicaid