Healthcare Provider Details

I. General information

NPI: 1093715666
Provider Name (Legal Business Name): PAUL RAYMOND FIELDSTONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 E FLORENCE BLVD STE 143
CASA GRANDE AZ
85222-4783
US

IV. Provider business mailing address

1828 E FLORENCE BLVD STE 143
CASA GRANDE AZ
85222-4783
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-2565
  • Fax: 520-836-2961
Mailing address:
  • Phone: 520-836-2565
  • Fax: 520-836-2961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD14584
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: