1215337381 NPI number — EL DORADO PROSTATE CENTER, PC

Table of content: (NPI 1215337381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215337381 NPI number — EL DORADO PROSTATE CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL DORADO PROSTATE CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1215337381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 98820
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89193-8820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-441-9520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 N EL DORADO PL
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:
85715-4606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-265-2797
Provider Business Practice Location Address Fax Number:
602-441-9524
Provider Enumeration Date:
08/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GREENBERG
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
520-403-7727

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  21528 , 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)





Copyright © 2007-2025 www.npivalidator.com