1346286275 NPI number — LAURA LISA VALDIVIA M.D.

Table of content: LAURA LISA VALDIVIA M.D. (NPI 1346286275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346286275 NPI number — LAURA LISA VALDIVIA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDIVIA
Provider First Name:
LAURA
Provider Middle Name:
LISA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1346286275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29675
Provider Second Line Business Mailing Address:
DEPARTMENT 2084
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85038-9675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-318-9681
Provider Business Mailing Address Fax Number:
520-325-6774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5230 E FARNESS DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-318-9681
Provider Business Practice Location Address Fax Number:
520-325-6774
Provider Enumeration Date:
06/21/2006

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: 207RI0200X , with the licence number:  31895 , 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: 953845 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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