Provider Demographics
NPI:1659415206
Name:SANJIVAN PLLC
Entity Type:Organization
Organization Name:SANJIVAN PLLC
Other - Org Name:AVONDALE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAFOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-932-9905
Mailing Address - Street 1:501 W VAN BUREN ST STE T
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1307
Mailing Address - Country:US
Mailing Address - Phone:623-932-9905
Mailing Address - Fax:623-386-6555
Practice Address - Street 1:501 W VAN BUREN ST STE T
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-932-9905
Practice Address - Fax:623-932-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ894099Medicaid
AZ894099Medicaid