Provider Demographics
NPI:1366413221
Name:PHELPS, CRAIG MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:MATTHEW
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 W BELL RD
Mailing Address - Street 2:STE 102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:602-588-4040
Mailing Address - Fax:602-588-4034
Practice Address - Street 1:4344 W BELL RD
Practice Address - Street 2:STE 102
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:602-588-4040
Practice Address - Fax:602-588-4034
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100262Medicare ID - Type Unspecified
D38802Medicare UPIN