1366544124 NPI number — JALDEEP H DAULAT DO PROFESSIONAL CORPORATION

Table of content: (NPI 1366544124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366544124 NPI number — JALDEEP H DAULAT DO PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JALDEEP H DAULAT DO PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOJAVE SKIN & CANCER CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366544124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 S VALADEZ ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89117-1970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-254-1588
Provider Business Mailing Address Fax Number:
702-243-5012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 S POINTE CIR
Provider Second Line Business Practice Location Address:
106
Provider Business Practice Location Address City Name:
LAUGHLIN
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89029-0424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-447-8405
Provider Business Practice Location Address Fax Number:
702-298-0524
Provider Enumeration Date:
09/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAULAT
Authorized Official First Name:
JALDEEP
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
702-254-1588

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  363 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CJ9248 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: CJ9249 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: P0220910 . This is a "BLUE CROSSBLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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