Basic Information
| Provider Information | |||||||||
| NPI: | 1235101262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HADDAD | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 E MISSOURI AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 E MISSOURI AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 31943 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00271092 | 01 | MEDICARE RAILROAD | OTHER | 850413 | 05 | AZ | MEDICAID |