Provider Demographics
NPI:1639152291
Name:GARTENBERG, ELISSA B (DO)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:B
Last Name:GARTENBERG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16211 N SCOTTSDALE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1584
Mailing Address - Country:US
Mailing Address - Phone:602-363-1631
Mailing Address - Fax:888-360-8644
Practice Address - Street 1:7522 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-4502
Practice Address - Country:US
Practice Address - Phone:602-363-1631
Practice Address - Fax:888-360-8644
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015264207Q00000X
AZ4155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ240988Medicaid
AZZ154007OtherMEDICARE PTAN
AZ240988Medicaid