Provider Demographics
NPI:1346273075
Name:OLD PUEBLO UROLOGY,LLC
Entity Type:Organization
Organization Name:OLD PUEBLO UROLOGY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-623-8475
Mailing Address - Street 1:445 N SILVERBELL RD
Mailing Address - Street 2:201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2685
Mailing Address - Country:US
Mailing Address - Phone:520-623-8475
Mailing Address - Fax:
Practice Address - Street 1:445 N SILVERBELL RD
Practice Address - Street 2:201
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2685
Practice Address - Country:US
Practice Address - Phone:520-623-8475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ925159Medicaid
AZCD3087OtherRAILROAD MEDICARE
AZ925159Medicaid