Provider Demographics
NPI:1689939985
Name:JONG, ANNIE (DPM)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:JONG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13660 N 94TH DR STE A3
Mailing Address - Street 2:STE A3
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4836
Mailing Address - Country:US
Mailing Address - Phone:623-933-4645
Mailing Address - Fax:623-933-4677
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:623-933-4677
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0000213E00000X
AZ0807213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ25945Medicaid
AZZ176984Medicare PIN