Basic Information
Provider Information | |||||||||
NPI: | 1861613275 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YU | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YU | ||||||||
OtherFirstName: | KEVIN | ||||||||
OtherMiddleName: | TZU-JUN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 8620 N 22ND AVE | ||||||||
Address2: | 200 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026746506 | ||||||||
FaxNumber: | 6026746512 | ||||||||
Practice Location | |||||||||
Address1: | 3929 E BELL RD | ||||||||
Address2: | DEPARTMENT OF INTERNAL MEDICINE | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029235000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 11/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41507 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 41507 | AZ | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 435921 | 05 | AZ |   | MEDICAID |