Provider Demographics
NPI:1134190093
Name:MAYO CLINIC ARIZONA
Entity type:Organization
Organization Name:MAYO CLINIC ARIZONA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:ROSHANAK
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDEHBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-301-6493
Mailing Address - Street 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5404
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5404
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2025-06-26
Deactivation Date:2012-01-06
Deactivation Code:
Reactivation Date:2012-09-11
Provider Licenses
StateLicense IDTaxonomies
AZ2856333600000X, 3336C0002X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0386430001Medicare NSC