1023076460 NPI number — SUSAN J MATURLO MD

Table of content: SUSAN J MATURLO MD (NPI 1023076460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023076460 NPI number — SUSAN J MATURLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATURLO
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023076460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2874 N CARSON ST
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89706-0251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-445-7170
Provider Business Mailing Address Fax Number:
775-687-8457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2874 N CARSON ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89706-0251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-445-7170
Provider Business Practice Location Address Fax Number:
775-687-8457
Provider Enumeration Date:
05/03/2006

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: 207RE0101X , with the licence number:  3562891205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: QM0000000062 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 344542 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 49453 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 990014449 . This is a "PALMETTO GBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107008206101 . This is a "IHC HEALTHPLANS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870281028000 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870281028MA1 . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com