1992782148 NPI number — DR. TIMOTHY WAYNE CASAREZ MD

Table of content: DR. TIMOTHY WAYNE CASAREZ MD (NPI 1992782148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992782148 NPI number — DR. TIMOTHY WAYNE CASAREZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASAREZ
Provider First Name:
TIMOTHY
Provider Middle Name:
WAYNE
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:
1992782148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5400 BALBOA BLVD
Provider Second Line Business Mailing Address:
SUITE 202 PEDIATRIC CARDIOLOGY MED ASSOC OF SO CAL
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91316-1502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-784-6269
Provider Business Mailing Address Fax Number:
818-784-1531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 BALBOA BLVD
Provider Second Line Business Practice Location Address:
SUITE 202 PEDIATRIC CARDIOLOGY MED ASSOC OF SO CAL
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-784-6269
Provider Business Practice Location Address Fax Number:
818-784-1531
Provider Enumeration Date:
12/29/2005

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: 2080P0202X , with the licence number:  A73301 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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