Basic Information
| Provider Information | |||||||||
| NPI: | 1598703977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SERNA | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | REN'E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 782 | ||||||||
| Address2: | 3740 LOMITA | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864020782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286921634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1510 STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287531177 | ||||||||
| FaxNumber: | 9287531178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/07/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 16279 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice | 208000000X | 16279 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.