Provider Demographics
NPI:1336120963
Name:NORTHERN ARIZONA RADIATION ONCOLOGY
Entity Type:Organization
Organization Name:NORTHERN ARIZONA RADIATION ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-204-4160
Mailing Address - Street 1:PO BOX 749560
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-9560
Mailing Address - Country:US
Mailing Address - Phone:770-693-2622
Mailing Address - Fax:770-693-6039
Practice Address - Street 1:1200 N. BEAVER STREET
Practice Address - Street 2:CANCER CENTER OF NORTHERN ARIZONA
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-2261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109498Medicaid
AZDC8937OtherRR MEDICARE
AZ0010949804Medicaid
AZDC8937OtherRR MEDICARE
AZZ82408Medicare PIN
AZZ82410Medicare PIN