Basic Information
Provider Information | |||||||||
NPI: | 1518128883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OGWARO | ||||||||
FirstName: | KISANI | ||||||||
MiddleName: | BERSBACH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OGWARO | ||||||||
OtherFirstName: | KISANI | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7091 E SPEEDWAY BLVD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857101241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207215777 | ||||||||
FaxNumber: | 5202987231 | ||||||||
Practice Location | |||||||||
Address1: | 7091 E SPEEDWAY BLVD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857101241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207215777 | ||||||||
FaxNumber: | 5202987231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2008 | ||||||||
LastUpdateDate: | 11/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 42542 | AZ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | FO1953389 | 01 | AZ | DEA | OTHER | AU-2903599-0460 | 01 | AZ | DEA | OTHER |