Provider Demographics
NPI:1992966998
Name:DIABETES AMERICA AZ LLC
Entity type:Organization
Organization Name:DIABETES AMERICA AZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-840-5245
Mailing Address - Street 1:13171 MISTY WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-5635
Mailing Address - Country:US
Mailing Address - Phone:832-237-3500
Mailing Address - Fax:832-237-0200
Practice Address - Street 1:2875 W RAY RD
Practice Address - Street 2:SUITE 16
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3524
Practice Address - Country:US
Practice Address - Phone:480-855-6075
Practice Address - Fax:480-855-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ407282Medicaid
AZ407282Medicaid