Provider Demographics
NPI:1932293032
Name:CORONADO INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:CORONADO INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-885-2072
Mailing Address - Street 1:PO BOX 43100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3100
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:6365 E TANQUE VERDE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3830
Practice Address - Country:US
Practice Address - Phone:520-885-2072
Practice Address - Fax:520-721-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ1182848Medicare PIN