Basic Information
Provider Information | |||||||||
NPI: | 1619941184 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EAST VALLEY NEUROLOGY P C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6532 E BRONCO DR | ||||||||
Address2: |   | ||||||||
City: | PARADISE VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 852533100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4809260644 | ||||||||
FaxNumber: | 4809260645 | ||||||||
Practice Location | |||||||||
Address1: | 2730 S VAL VISTA DR | ||||||||
Address2: | SUITE #146 | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852966675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4809260644 | ||||||||
FaxNumber: | 4809260645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROOT | ||||||||
AuthorizedOfficialFirstName: | KEN | ||||||||
AuthorizedOfficialMiddleName: | ERNEST | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4809260644 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 1688 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.