Provider Demographics
NPI:1972593929
Name:LIN, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 W ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2530
Mailing Address - Country:US
Mailing Address - Phone:623-931-7999
Mailing Address - Fax:623-842-5640
Practice Address - Street 1:5605 W EUGIE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1273
Practice Address - Country:US
Practice Address - Phone:623-847-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ288532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ548505Medicaid
AZ548505Medicaid
AZZ65308Medicare PIN
AZZ128188Medicare PIN
AZZ79264Medicare PIN