Provider Demographics
NPI:1669987566
Name:MAXAM, ROBERT E (SA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:MAXAM
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 E CHICO LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85739-9726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3831 E CHICO LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-9726
Practice Address - Country:US
Practice Address - Phone:520-549-9685
Practice Address - Fax:520-549-9685
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17-410208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery