Healthcare Provider Details

I. General information

NPI: 1700230109
Provider Name (Legal Business Name): GINO JOSE BARDI LOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 02/14/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E 15TH ST
DOUGLAS AZ
85607-1631
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-5437
  • Fax:
Mailing address:
  • Phone: 520-459-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65304
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: