Provider Demographics
NPI:1215960638
Name:DESERET FAMILY PRACTICE, LTD.
Entity type:Organization
Organization Name:DESERET FAMILY PRACTICE, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-981-3000
Mailing Address - Street 1:1425 S GREENFIELD RD
Mailing Address - Street 2:101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5529
Mailing Address - Country:US
Mailing Address - Phone:480-981-3000
Mailing Address - Fax:480-654-5761
Practice Address - Street 1:1425 S GREENFIELD RD
Practice Address - Street 2:101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5529
Practice Address - Country:US
Practice Address - Phone:480-981-3000
Practice Address - Fax:480-654-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4101111N00000X
AZ006034204D00000X
207Q00000X, 207R00000X, 261QM1300X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZDWBNHMedicare PIN
AZZWDBNHMedicare PIN
AZZWDCFSMedicare PIN