Healthcare Provider Details

I. General information

NPI: 1598703977
Provider Name (Legal Business Name): JOE REN'E SERNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 STOCKTON HILL RD
KINGMAN AZ
86401-5173
US

IV. Provider business mailing address

PO BOX 782 3740 LOMITA
KINGMAN AZ
86402-0782
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-1177
  • Fax: 928-753-1178
Mailing address:
  • Phone: 928-692-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16279
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16279
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: