1134225592 NPI number — BOTOND A VITA PA

Table of content: BOTOND A VITA PA (NPI 1134225592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134225592 NPI number — BOTOND A VITA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VITA
Provider First Name:
BOTOND
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1134225592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 BLANCA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOSA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81101-2340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-589-3000
Provider Business Mailing Address Fax Number:
719-587-1372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 STUART AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOSA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81101-2269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-589-8091
Provider Business Practice Location Address Fax Number:
719-589-8112
Provider Enumeration Date:
09/15/2006

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: 363A00000X , with the licence number:  00380 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2460 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VIVI2460 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 840255530069 . This is a "ROCKY MTN HEALTH PLANS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 56582722 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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