Provider Demographics
NPI:1922055730
Name:KAPELLEN, PHYLLIS JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JEAN
Last Name:KAPELLEN
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 1:417 E NATASHA CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-7383
Mailing Address - Country:US
Mailing Address - Phone:520-989-9994
Mailing Address - Fax:
Practice Address - Street 1:417 E NATASHA CT
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85737-7383
Practice Address - Country:US
Practice Address - Phone:520-989-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350860512085R0202X
FLME998002085R0202X
OK260302085R0202X
WI42462-202085R0202X
TXN51472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200270870AMedicaid
OKOK404533Medicare PIN