1962407429 NPI number — DR. SETH K ADJOVU MD

Table of content: DR. SETH K ADJOVU MD (NPI 1962407429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962407429 NPI number — DR. SETH K ADJOVU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADJOVU
Provider First Name:
SETH
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1962407429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N BEAVER ST
Provider Second Line Business Mailing Address:
PAYER CREDENTIALING
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-773-2559
Provider Business Mailing Address Fax Number:
928-213-6292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
269 S CANDY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COTTONWOOD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86326-4158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-639-5588
Provider Business Practice Location Address Fax Number:
928-639-5589
Provider Enumeration Date:
06/20/2005

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: 207R00000X , with the licence number:  10335 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 10335 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 41762 , 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: 2018988 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3102988 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100500484 GROUP , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 184241 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".