Basic Information
Provider Information | |||||||||
NPI: | 1164489050 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BORNSTEIN | ||||||||
FirstName: | AARON | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
Address2: |   | ||||||||
City: | SHOW LOW | ||||||||
State: | AZ | ||||||||
PostalCode: | 85901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9285376978 | ||||||||
FaxNumber: | 9285374205 | ||||||||
Practice Location | |||||||||
Address1: | 2352 QUARTER HORSE TRAIL | ||||||||
Address2: |   | ||||||||
City: | OVERGAARD | ||||||||
State: | AZ | ||||||||
PostalCode: | 85933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9285353616 | ||||||||
FaxNumber: | 9285353615 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 12/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 14650 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 240771 | 05 | AZ |   | MEDICAID |