1679736193 NPI number — JOSELYN JEDICK BRANCHIK DO

Table of content: JOSELYN JEDICK BRANCHIK DO (NPI 1679736193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679736193 NPI number — JOSELYN JEDICK BRANCHIK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANCHIK
Provider First Name:
JOSELYN
Provider Middle Name:
JEDICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JEDICK
Provider Other First Name:
JOSELYN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679736193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86003-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-522-9879
Provider Business Mailing Address Fax Number:
928-522-9880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2090 SMOKETREE AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-1800
Provider Business Practice Location Address Fax Number:
928-854-1847
Provider Enumeration Date:
07/03/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R70138 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 005490 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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