1952623100 NPI number — ESTRELLA EAR, NOSE AND THROAT PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952623100 NPI number — ESTRELLA EAR, NOSE AND THROAT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESTRELLA EAR, NOSE AND THROAT 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:
1952623100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-535-8770
Provider Business Mailing Address Fax Number:
623-535-8771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 N 140TH AVE
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-535-8770
Provider Business Practice Location Address Fax Number:
623-535-8771
Provider Enumeration Date:
02/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WIGGENHORN
Authorized Official First Name:
JONATHON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-535-8770

Provider Taxonomy Codes

  • Taxonomy code: 207YS0123X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 497110 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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