Basic Information
| Provider Information | |||||||||
| NPI: | 1003963216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILL UROLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 S RAYMOND AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267958454 | ||||||||
| FaxNumber: | 6267955631 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 S RAYMOND AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267958454 | ||||||||
| FaxNumber: | 6267955631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOTO | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6267958454 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | CN2645 | 01 | CA | MEDICARE RR | OTHER | ZZZ33990Z | 01 | CA | BLUE SHIELD | OTHER |