1053303867 NPI number — DESERT PEDIATRIC SPECIALTY CARE PC

Table of content: JOHN NONDA KATOPODIS M.D. (NPI 1477559623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053303867 NPI number — DESERT PEDIATRIC SPECIALTY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT PEDIATRIC SPECIALTY CARE PC
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:
Provider Other Organization Name Type Code:
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:
1053303867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 E CAREFREE HWY
Provider Second Line Business Mailing Address:
PMB 1126
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85085-8839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-465-9866
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43220 N 24TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW RIVER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85087-8626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-465-9866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HURWITZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-465-9866

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  22057 , 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)

  • Identifier: 172065 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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