Basic Information
| Provider Information | |||||||||
| NPI: | 1376723999 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLD PUEBLO PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 N LA CHOLLA BLVD # 154-501 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207977070 | ||||||||
| FaxNumber: | 5207977077 | ||||||||
| Practice Location | |||||||||
| Address1: | 3043 W INA RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207977070 | ||||||||
| FaxNumber: | 5207977077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | BEAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5207977070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M. D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |
No ID Information.