Provider Demographics
NPI:1972569200
Name:PEDERSEN, DAVID ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1712 W ANKLAM RD
Mailing Address - Street 2:STE 103
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2660
Mailing Address - Country:US
Mailing Address - Phone:520-622-7384
Mailing Address - Fax:520-622-4899
Practice Address - Street 1:1712 W ANKLAM RD
Practice Address - Street 2:STE 103
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2660
Practice Address - Country:US
Practice Address - Phone:520-622-7384
Practice Address - Fax:520-622-4899
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-11-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ23255208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ313099Medicaid
AZ313099Medicaid
AZG04815Medicare UPIN