1376835561 NPI number — MR. JOHN CHARLES WAITE

Table of content: MR. JOHN CHARLES WAITE (NPI 1376835561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376835561 NPI number — MR. JOHN CHARLES WAITE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAITE
Provider First Name:
JOHN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1376835561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1161 N EL DORADO PL STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85715-4607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-748-7108
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8501 E SHILOH ST
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:
85710-2941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-490-5906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2011

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: 253J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385HR2055X , with the licence number: 2838615 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 613805 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com