Provider Demographics
NPI:1598944811
Name:LAKE HAVASU OB/GYN, PC
Entity Type:Organization
Organization Name:LAKE HAVASU OB/GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:VITA
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-680-2846
Mailing Address - Street 1:99 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5713
Mailing Address - Country:US
Mailing Address - Phone:928-680-2846
Mailing Address - Fax:928-680-2845
Practice Address - Street 1:99 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5713
Practice Address - Country:US
Practice Address - Phone:928-680-2846
Practice Address - Fax:928-680-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3696261QM2500X
CA20A8265261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ434157Medicaid
AZH51127Medicare UPIN
AZZ77612Medicare PIN