Provider Demographics
NPI:1124751227
Name:YAVAPAI UROLOGY, PLLC
Entity type:Organization
Organization Name:YAVAPAI UROLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYMPHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-208-1182
Mailing Address - Street 1:1042 WILLOW CREEK RD STE A101-138
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 ROTONDA WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-4493
Practice Address - Country:US
Practice Address - Phone:661-208-1182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty