Provider Demographics
NPI:1861497950
Name:LECAVALIER, MARY ANN ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:ANN
Last Name:LECAVALIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 N SCOTTSDALE RD.
Mailing Address - Street 2:#603
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5216
Mailing Address - Country:US
Mailing Address - Phone:480-607-3800
Mailing Address - Fax:480-607-3808
Practice Address - Street 1:10900 N SCOTTSDALE RD.
Practice Address - Street 2:#603
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5216
Practice Address - Country:US
Practice Address - Phone:480-607-3800
Practice Address - Fax:480-607-3808
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25063207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080186441OtherRAIL ROAD
AZAZ0729180OtherBSBSAZ
AZ398059Medicaid
AZG48077Medicare UPIN
AZ398059Medicaid
AZAZ0729180OtherBSBSAZ