Provider Demographics
NPI:1104963412
Name:ROMANOFF, CHAD
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:ROMANOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 E CHANDLER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0425
Mailing Address - Country:US
Mailing Address - Phone:480-893-6514
Mailing Address - Fax:
Practice Address - Street 1:930 W SOUTHERN AVE
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4938
Practice Address - Country:US
Practice Address - Phone:480-835-0857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2504225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ556821Medicaid