Provider Demographics
NPI:1720153810
Name:GILBERT PRIMARY CARE PC
Entity Type:Organization
Organization Name:GILBERT PRIMARY CARE PC
Other - Org Name:GILBERT PRIMARY CARE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-505-3292
Mailing Address - Street 1:3048 E BASELINE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204
Mailing Address - Country:US
Mailing Address - Phone:480-505-3292
Mailing Address - Fax:480-505-3288
Practice Address - Street 1:3048 E BASELINE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-505-3292
Practice Address - Fax:480-505-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207Q00000X, 207R00000X
207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z64475Medicare UPIN