Provider Demographics
NPI:1497074173
Name:YUMA GASTRO LLC
Entity Type:Organization
Organization Name:YUMA GASTRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:DIVESH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-726-5151
Mailing Address - Street 1:1390 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4430
Mailing Address - Country:US
Mailing Address - Phone:928-344-4325
Mailing Address - Fax:928-344-3084
Practice Address - Street 1:1390 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4430
Practice Address - Country:US
Practice Address - Phone:928-344-4325
Practice Address - Fax:928-344-3084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529143Medicaid
AZZ139296Medicare PIN