Provider Demographics
NPI:1740596733
Name:ARIZONA FAMILY & GERIATRIC MEDICINE PLLC
Entity Type:Organization
Organization Name:ARIZONA FAMILY & GERIATRIC MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINH
Authorized Official - Middle Name:
Authorized Official - Last Name:LUONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-854-9004
Mailing Address - Street 1:5602 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205
Mailing Address - Country:US
Mailing Address - Phone:480-854-9004
Mailing Address - Fax:480-832-1858
Practice Address - Street 1:5602 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205
Practice Address - Country:US
Practice Address - Phone:480-854-9004
Practice Address - Fax:480-832-1858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41809261QP2300X
AZ261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOB1083820761Medicare PIN