Provider Demographics
NPI:1770888281
Name:CORDIVIN, SAMUEL E (RT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:CORDIVIN
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 E SIOUX DR
Mailing Address - Street 2:11A
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6668
Mailing Address - Country:US
Mailing Address - Phone:928-640-0337
Mailing Address - Fax:
Practice Address - Street 1:3480 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4032
Practice Address - Country:US
Practice Address - Phone:928-863-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ157272471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography