Provider Demographics
NPI:1942488861
Name:SONORAN SPORTS & FAMILY MEDICINE PLC
Entity Type:Organization
Organization Name:SONORAN SPORTS & FAMILY MEDICINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-802-1300
Mailing Address - Street 1:3930 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4510
Mailing Address - Country:US
Mailing Address - Phone:480-802-1300
Mailing Address - Fax:480-802-1359
Practice Address - Street 1:3930 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 8
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4510
Practice Address - Country:US
Practice Address - Phone:480-802-1300
Practice Address - Fax:480-802-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ926876Medicaid
AZ926876Medicaid
AZZ102190Medicare PIN