Provider Demographics
NPI:1376723999
Name:OLD PUEBLO PEDIATRICS
Entity Type:Organization
Organization Name:OLD PUEBLO PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:520-797-7070
Mailing Address - Street 1:7320 N LA CHOLLA BLVD # 154-501
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2309
Mailing Address - Country:US
Mailing Address - Phone:520-797-7070
Mailing Address - Fax:520-797-7077
Practice Address - Street 1:3043 W INA RD STE 115
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2107
Practice Address - Country:US
Practice Address - Phone:520-797-7070
Practice Address - Fax:520-797-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty