1881661940 NPI number — CARLOS MOE DO

Table of content: CARLOS MOE DO (NPI 1881661940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881661940 NPI number — CARLOS MOE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOE
Provider First Name:
CARLOS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1881661940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 32950
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-433-1822
Provider Business Mailing Address Fax Number:
602-246-7060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8260 W INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
STE 1 AND 2
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-846-7122
Provider Business Practice Location Address Fax Number:
623-846-7027
Provider Enumeration Date:
03/07/2006

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:  3642 , 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: 84270 . This is a "MEDICARE PIN #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 705329 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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