1821089624 NPI number — DR. BRADLEY WHITAKER DPM., FACFAS

Table of content: HOWARD SMITH PHARMD (NPI 1962590547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821089624 NPI number — DR. BRADLEY WHITAKER DPM., FACFAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITAKER
Provider First Name:
BRADLEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM., FACFAS
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:
1821089624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2163 W ORANGE GROVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85741-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-575-0800
Provider Business Mailing Address Fax Number:
520-575-0093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2163 W ORANGE GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85741-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-575-0800
Provider Business Practice Location Address Fax Number:
520-575-0093
Provider Enumeration Date:
10/31/2005

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: 213ES0103X , with the licence number:  0446 , 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: 337627 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5507194 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 6287561009 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z3482 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 480030868 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0191940 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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