Basic Information
| Provider Information | |||||||||
| NPI: | 1710180401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIK DE JONGHE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727383 | ||||||||
| FaxNumber: | 5208727969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 W ST MARYS RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727383 | ||||||||
| FaxNumber: | 5208727969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | FREDERIKSEN | ||||||||
| AuthorizedOfficialFirstName: | KIRSTEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5206150318 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 31026 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 805228 | 05 | AZ | MEDICAID |