Provider Demographics
NPI:1457518391
Name:EHTESHAMI, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:EHTESHAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20280 N 59TH AVE STE 115-345
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:602-377-2616
Mailing Address - Fax:480-656-1554
Practice Address - Street 1:20280 N 59TH AVE STE 115-345
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6850
Practice Address - Country:US
Practice Address - Phone:602-377-2616
Practice Address - Fax:480-656-1554
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41787207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ487862Medicaid
AZZ176476Medicare PIN
AZP00842000Medicare PIN
AZZ136768Medicare PIN