NPIMap

Organization Active NPI

Mira Vita Metamophosis, LLC

  • Internal Medicine Physician
  • Glendale, AZ
National Provider Identifier
1073910873
Registry record updated Jan 30, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
4223 Issued in AZ
Legal business name
MIRA VITA METAMOPHOSIS, LLC
Practice address
5620 W Thunderbird Rd Ste H2
Glendale, AZ 85306-4653
Phone
(480) 407-9007
Fax
(833) 817-6790
NPI assigned
Nov 24, 2014
Last updated
Jan 30, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angela Marie Derosa, DONPI 1992728729
Title
Owner
Phone
(480) 619-4097

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 4223 AZ Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X

Addresses

Primary practice location

5620 W Thunderbird Rd Ste H2
Glendale, AZ 85306-4653

Mailing address

5620 W Thunderbird Rd Ste H2
Glendale, AZ 85306-4653
Phone (480) 407-9007

National Provider Directory

National Provider Directory

Locations

5620 W Thunderbird Rd
Ste H2
Glendale, AZ 85306
Phone (480) 407-9007

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1416787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1580342400000",
    "number": "1073910873",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5620 W THUNDERBIRD RD STE H2",
            "city": "GLENDALE",
            "state": "AZ",
            "postal_code": "853064653",
            "telephone_number": "480-407-9007",
            "fax_number": "833-817-6790"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5620 W THUNDERBIRD RD STE H2",
            "city": "GLENDALE",
            "state": "AZ",
            "postal_code": "853064653",
            "telephone_number": "480-407-9007",
            "fax_number": "833-817-6790"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRA VITA METAMOPHOSIS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-11-24",
        "last_updated": "2020-01-30",
        "certification_date": "2020-01-30",
        "status": "A",
        "authorized_official_last_name": "DEROSA",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "480-619-4097",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "AZ",
            "license": "4223",
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Glendale, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.