Provider Demographics
NPI:1710067681
Name:DARDIS, MARK WILLIAM (ND, EDD, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:DARDIS
Suffix:
Gender:M
Credentials:ND, EDD, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15424 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0400
Mailing Address - Country:US
Mailing Address - Phone:480-460-0669
Mailing Address - Fax:
Practice Address - Street 1:15424 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-0400
Practice Address - Country:US
Practice Address - Phone:480-460-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS21-00039175F00000X
KS11-00596225100000X
AZ8414225100000X
CA93100003792251H1200X
AZ16-1548175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ456071Medicaid
AZ030078 8HZ10EMedicare ID - Type UnspecifiedPART A PART B
P37421Medicare UPIN