Provider Demographics
NPI:1881772317
Name:SOUTHWEST DIABETES CENTER PLLC
Entity type:Organization
Organization Name:SOUTHWEST DIABETES CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENAHERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-6450
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-0590
Mailing Address - Country:US
Mailing Address - Phone:928-344-6450
Mailing Address - Fax:928-344-6480
Practice Address - Street 1:3800 W 24TH ST
Practice Address - Street 2:1
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6298
Practice Address - Country:US
Practice Address - Phone:928-344-6450
Practice Address - Fax:928-344-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167090003Medicaid
AZZ68148Medicare ID - Type Unspecified
AZ167090003Medicaid