Provider Demographics
NPI:1730462235
Name:TAMAR K GOTTFRIED MD, PLC
Entity Type:Organization
Organization Name:TAMAR K GOTTFRIED MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-545-0059
Mailing Address - Street 1:1520 S DOBSON RD
Mailing Address - Street 2:SUITE 316
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4725
Mailing Address - Country:US
Mailing Address - Phone:480-545-0059
Mailing Address - Fax:480-632-2134
Practice Address - Street 1:1520 S DOBSON RD
Practice Address - Street 2:SUITE 316
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4725
Practice Address - Country:US
Practice Address - Phone:480-545-0059
Practice Address - Fax:480-632-2134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26354261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422650Medicaid