1992069637 NPI number — MOHAVE INFECTIOUS DISEASE,PLLC

Table of content: (NPI 1992069637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992069637 NPI number — MOHAVE INFECTIOUS DISEASE,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAVE INFECTIOUS DISEASE,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:
1992069637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1840 MESQUITE AVE
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86403-5771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-854-1242
Provider Business Mailing Address Fax Number:
928-854-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 MESQUITE AVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-1242
Provider Business Practice Location Address Fax Number:
928-854-1243
Provider Enumeration Date:
06/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BUSSELL
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
928-854-1242

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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