1265464424 NPI number — JAVELINA PEDIATRICS PLLC

Table of content: (NPI 1265464424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265464424 NPI number — JAVELINA PEDIATRICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAVELINA PEDIATRICS PLLC
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:
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:
1265464424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1521 E TANGERINE RD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
ORO VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85755-6225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-531-0060
Provider Business Mailing Address Fax Number:
520-225-0156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 E TANGERINE RD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ORO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85755-6225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-531-0060
Provider Business Practice Location Address Fax Number:
520-225-0156
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRAQUAIR
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
520-531-0060

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  33911 , 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: 945925 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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