1124180054 NPI number — DR. SAMUEL PONCE NANDIN M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124180054 NPI number — DR. SAMUEL PONCE NANDIN M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

NANDIN

Provider First Name:

SAMUEL

Provider Middle Name:

PONCE

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1124180054

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/21/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

13851 W LA MAR BLVD

Provider Second Line Business Mailing Address:

STE C

Provider Business Mailing Address City Name:

GOODYEAR

Provider Business Mailing Address State Name:

AZ

Provider Business Mailing Address Postal Code:

85338-1389

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

623-925-2622

Provider Business Mailing Address Fax Number:

623-925-9260

Provider First Line Business Practice Location Address:

13851 W LA MAR BLVD

Provider Second Line Business Practice Location Address:

STE C

Provider Business Practice Location Address City Name:

GOODYEAR

Provider Business Practice Location Address State Name:

AZ

Provider Business Practice Location Address Postal Code:

85338-1389

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

623-925-2622

Provider Business Practice Location Address Fax Number:

623-925-9260

Provider Enumeration Date:

12/15/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208D00000X , with the licence number:  AZ15582 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 106223600 . This is a "OWCP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "AZ. FOUNDATION FOR MEDICA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "LIFE WISE HEALTHPLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "UNITEDHEALTH CARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "SCF OF ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: AZ0766630 . This is a "BCBS OF AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "HUMANA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 273607001 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 562491245 . This is a "BEECHSTREET NETWORK" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 2Z1748 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 5008111 . This is a "AETNA PROVIDER NO." identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".