Provider Demographics
NPI:1710180401
Name:ERIK DE JONGHE MD PC
Entity Type:Organization
Organization Name:ERIK DE JONGHE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERIKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-615-0318
Mailing Address - Street 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-872-7383
Mailing Address - Fax:520-872-7969
Practice Address - Street 1:1601 W ST MARYS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745
Practice Address - Country:US
Practice Address - Phone:520-872-7383
Practice Address - Fax:520-872-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805228Medicaid
G73699Medicare UPIN
AZ805228Medicaid