Basic Information
| Provider Information | |||||||||
| NPI: | 1841291804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABEYTA | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | JUDE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 645 E MISSOURI AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Practice Location | |||||||||
| Address1: | 3390 N CAMPBELL AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857192380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207957650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | L9049 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2003-0436 | NM | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 51249 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BA8788575 | 01 | DEA | OTHER | 202013736 | 01 | NM | PHP | OTHER | 168654501 | 05 | TX | MEDICAID | H0134723 | 01 | TX | DPS | OTHER |