Healthcare Provider Details

I. General information

NPI: 1427504299
Provider Name (Legal Business Name): GEORGE P JOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2082 MESQUITE AVE STE 100A
LAKE HAVASU CITY AZ
86403-6710
US

IV. Provider business mailing address

PMB-532, 100 WOODS RD
VALHALLA NY
10595
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-2727
  • Fax: 928-453-2828
Mailing address:
  • Phone: 347-294-6206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301504730
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number70206
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number70206
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: