Basic Information
Provider Information | |||||||||
NPI: | 1063667293 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YUMA EYE SURGERY CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1375 W 16TH ST | ||||||||
Address2: | SUITE B | ||||||||
City: | YUMA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853644497 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287821980 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1375 W 16TH ST | ||||||||
Address2: | SUITE B | ||||||||
City: | YUMA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853644497 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287821980 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2008 | ||||||||
LastUpdateDate: | 12/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AIELLO | ||||||||
AuthorizedOfficialFirstName: | PATRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER / MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9287821980 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | NOT APPLICABLE | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.