1912230178 NPI number — MS. MOZELLE BARR MARTIN PHD

Table of content: JEFFERY J DIXON (NPI 1952951956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912230178 NPI number — MS. MOZELLE BARR MARTIN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
MOZELLE
Provider Middle Name:
BARR
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1912230178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/24/2018
NPI Reactivation Date:
09/25/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 S. 5TH AVE.
Provider Second Line Business Mailing Address:
#1427
Provider Business Mailing Address City Name:
SAFFORD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-985-5050
Provider Business Mailing Address Fax Number:
602-733-6538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3734 W. VISTA AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-850-8198
Provider Business Practice Location Address Fax Number:
888-306-2742
Provider Enumeration Date:
09/04/2009

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , with the licence number: P0214763 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175L00000X , with the licence number: 00012 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , 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)