Provider Demographics
NPI:1841482577
Name:YUMA UROLOGY CENTER PLLC
Entity type:Organization
Organization Name:YUMA UROLOGY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATAKOM
Authorized Official - Middle Name:NASH
Authorized Official - Last Name:CHULAMORKODT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-501-7706
Mailing Address - Street 1:PO BOX 6514
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2522
Mailing Address - Country:US
Mailing Address - Phone:928-257-8699
Mailing Address - Fax:928-341-1973
Practice Address - Street 1:2275 S ELKS LN
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6258
Practice Address - Country:US
Practice Address - Phone:928-341-1900
Practice Address - Fax:928-341-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37017261QM2500X
208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1043388481Medicaid