Basic Information
Provider Information | |||||||||
NPI: | 1942286034 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DURSTELER | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | BRUCE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7021 E EARLL DR | ||||||||
Address2: | STE 202 | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852516318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4809492764 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13677 W MCDOWELL RD | ||||||||
Address2: |   | ||||||||
City: | GOODYEAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 853382618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238821500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 28901 | AZ | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3981220 | 01 | AZ | EVERCARE GROUP | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS & BLUE SHIELD | OTHER | AW1436 | 01 |   | HEALTHNET GROUP | OTHER | 545486 | 05 | AZ |   | MEDICAID |