Basic Information
Provider Information | |||||||||
NPI: | 1932198652 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUWE | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8475 E HARTFORD DR STE 201 | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852555477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4805919345 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2301 N 4TH ST | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860043708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287197400 | ||||||||
FaxNumber: | 9284405399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2005 | ||||||||
LastUpdateDate: | 08/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 47637 | CO | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 12685 | MT | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 30288 | AZ | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 12685 | MT | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 30288 | AZ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | 698409 | 05 | AZ |   | MEDICAID | 1932198652 | 05 | MT |   | MEDICAID | 30288 | 01 | AZ | STATE LICENSE | OTHER | 82724865 | 05 | CO |   | MEDICAID |