Basic Information
Provider Information | |||||||||
NPI: | 1063477495 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUKUNOOR | ||||||||
FirstName: | VIMALA | ||||||||
MiddleName: | NADINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 W UTOPIA RD | ||||||||
Address2: | STE. 100 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850274171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022146148 | ||||||||
FaxNumber: | 6022146149 | ||||||||
Practice Location | |||||||||
Address1: | 9100 N 2ND ST | ||||||||
Address2: | SUITE 121 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850202446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029977331 | ||||||||
FaxNumber: | 6028704512 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 09/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34515 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.