Healthcare Provider Details

I. General information

NPI: 1548372089
Provider Name (Legal Business Name): YURI TALALAEV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4672 MAVERICK LN STE 1A
LAKESIDE AZ
85929-5434
US

IV. Provider business mailing address

4672 MAVERICK LN STE 1A
LAKESIDE AZ
85929-5434
US

V. Phone/Fax

Practice location:
  • Phone: 928-288-0123
  • Fax: 877-682-6132
Mailing address:
  • Phone: 928-288-0123
  • Fax: 877-682-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28484
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: