1508869488 NPI number — DR. JOHN J HETHERINGTON PH.D.

Table of content: DR. JOHN J HETHERINGTON PH.D. (NPI 1508869488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508869488 NPI number — DR. JOHN J HETHERINGTON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETHERINGTON
Provider First Name:
JOHN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1508869488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
177 W COTTONWOOD LN
Provider Second Line Business Mailing Address:
STE 7
Provider Business Mailing Address City Name:
CASA GRANDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85222-2552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-836-4618
Provider Business Mailing Address Fax Number:
520-836-2650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 W COTTONWOOD LN
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
CASA GRANDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85222-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-836-4618
Provider Business Practice Location Address Fax Number:
520-836-2650
Provider Enumeration Date:
05/24/2005

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: 231H00000X , with the licence number:  DA4090 , 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: 1Z2179 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 802117 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZOO76260 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 133376 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".