Provider Demographics
NPI:1679570832
Name:MEDEIROS, MARK M (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MEDEIROS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:10210 N 92ND ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4509
Mailing Address - Country:US
Mailing Address - Phone:480-551-6979
Mailing Address - Fax:480-551-9725
Practice Address - Street 1:10210 N 92ND ST
Practice Address - Street 2:SUITE 305
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4509
Practice Address - Country:US
Practice Address - Phone:480-551-6979
Practice Address - Fax:480-551-9725
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-02
Last Update Date:2011-06-22
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Provider Licenses
StateLicense IDTaxonomies
AZ18965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E83138Medicare UPIN
65204Medicare PIN