Provider Demographics
NPI:1104907039
Name:EAST VALLEY INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:EAST VALLEY INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:D'ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-821-3821
Mailing Address - Street 1:655 S DOBSON RD
Mailing Address - Street 2:STE A-201
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5667
Mailing Address - Country:US
Mailing Address - Phone:480-821-3821
Mailing Address - Fax:480-857-4393
Practice Address - Street 1:2081 W FRYE RD STE 200
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6279
Practice Address - Country:US
Practice Address - Phone:480-821-3821
Practice Address - Fax:877-799-4622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF01456Medicaid
AZF01456Medicaid