Provider Demographics
NPI:1902804974
Name:JAN, MINDY (MD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:JAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 N. BEVERLY AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2154
Mailing Address - Country:US
Mailing Address - Phone:520-327-6265
Mailing Address - Fax:520-327-9300
Practice Address - Street 1:1645 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4046
Practice Address - Country:US
Practice Address - Phone:520-327-6265
Practice Address - Fax:520-327-9300
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-10-04
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
AZ33714207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ917958Medicaid
101905Medicare ID - Type Unspecified
I26788Medicare UPIN