Basic Information
Provider Information | |||||||||
NPI: | 1417926056 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUNOZ | ||||||||
FirstName: | JOHNATHON | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MUNOZ | ||||||||
OtherFirstName: | JOHNNY | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 N BEAVER ST | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860013118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282136235 | ||||||||
FaxNumber: | 9282136292 | ||||||||
Practice Location | |||||||||
Address1: | 3700 W STATE ROUTE 89A | ||||||||
Address2: |   | ||||||||
City: | SEDONA | ||||||||
State: | AZ | ||||||||
PostalCode: | 863364937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282044100 | ||||||||
FaxNumber: | 9282044115 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2006 | ||||||||
LastUpdateDate: | 04/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME 113250 | FL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 52306 | AZ | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 009998225 | 05 | AL |   | MEDICAID | 051529486 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER |