1023011269 NPI number — BENIGNO F DECENA III MD

Table of content: BENIGNO F DECENA III MD (NPI 1023011269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023011269 NPI number — BENIGNO F DECENA III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECENA
Provider First Name:
BENIGNO
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
1023011269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3709 N CAMPBELL AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85719-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-838-2138
Provider Business Mailing Address Fax Number:
520-624-2798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4729 E CAMP LOWELL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-1256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-838-3540
Provider Business Practice Location Address Fax Number:
520-325-3526
Provider Enumeration Date:
05/23/2005

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: 207RC0000X , with the licence number:  32303 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 32303 , 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: 2198100 . This is a "GHI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2Z0331 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 830340 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2079115 . This is a "FIRST HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: P00084839 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 5427615 . This is a "CCN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7597308 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 886331 . This is a "USA MANAGED CARE ORGANIZA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0743710 . This is a "BCBS OF ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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