Provider Demographics
NPI:1952592339
Name:LAKE HAVASU RADIOLOGY, PLLC
Entity Type:Organization
Organization Name:LAKE HAVASU RADIOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-0802
Mailing Address - Street 1:PO BOX 1766
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-1766
Mailing Address - Country:US
Mailing Address - Phone:337-721-1961
Mailing Address - Fax:337-721-1939
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-453-6236
Practice Address - Fax:928-453-7809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ63271Medicare PIN