1235176207 NPI number — GERALD L OLDHAM MD

Table of content: GERALD L OLDHAM MD (NPI 1235176207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235176207 NPI number — GERALD L OLDHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLDHAM
Provider First Name:
GERALD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1235176207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13640 N PLAZA DEL RIO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-4846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-876-3800
Provider Business Mailing Address Fax Number:
623-876-3809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13640 N PLAZA DEL RIO BLVD
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-4846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-876-3850
Provider Business Practice Location Address Fax Number:
623-876-3809
Provider Enumeration Date:
05/31/2006

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: 207R00000X , with the licence number:  10076 , 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: 267642 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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