Provider Demographics
NPI:1881997484
Name:CASA GRANDE INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:CASA GRANDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:T
Authorized Official - Last Name:ZARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-229-2443
Mailing Address - Street 1:1637 E MONUMENT PLAZA CIRCLE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122
Mailing Address - Country:US
Mailing Address - Phone:520-426-1512
Mailing Address - Fax:
Practice Address - Street 1:1637 E MONUMENT PLAZA CIRCLE
Practice Address - Street 2:SUITE 1
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:520-426-1512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29958Medicare PIN