Provider Demographics
NPI:1861545048
Name:DATTILO, PHILLIP JOHN (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOHN
Last Name:DATTILO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1404 EAST PRINCE ROAD
Mailing Address - Street 2:TUCSON CARDIOLOGY LTD
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719
Mailing Address - Country:US
Mailing Address - Phone:520-327-7494
Mailing Address - Fax:520-327-7493
Practice Address - Street 1:1404 EAST PRINCE ROAD
Practice Address - Street 2:TUCSON CARDIOLOGY LTD
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719
Practice Address - Country:US
Practice Address - Phone:520-327-7494
Practice Address - Fax:520-327-7493
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ241207R00000X, 207RC0000X
AZ13207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ228420Medicaid
AZ228420Medicaid