Basic Information
| Provider Information | |||||||||
| NPI: | 1174701643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT SPINE SURGEONS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12361 W BOLA DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235845626 | ||||||||
| FaxNumber: | 6235449122 | ||||||||
| Practice Location | |||||||||
| Address1: | 12361 W BOLA DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235845626 | ||||||||
| FaxNumber: | 6235449122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | WALDRIP | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6235845626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.