Basic Information
| Provider Information | |||||||||
| NPI: | 1528261179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORO VALLEY VEIN CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43160 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 7620 N LA CHOLLA BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857414201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205310900 | ||||||||
| FaxNumber: | 5206185611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAHUREKSA | ||||||||
| AuthorizedOfficialFirstName: | BUDI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5205310900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 3901 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 230203 | 05 | AZ | MEDICAID |