Healthcare Provider Details

I. General information

NPI: 1528053261
Provider Name (Legal Business Name): DANIEL C REGOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BURRO ALY
MORENCI AZ
85540-9647
US

IV. Provider business mailing address

PO BOX 218
MORENCI AZ
85540-0218
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-9184
  • Fax: 928-865-9186
Mailing address:
  • Phone: 928-865-9184
  • Fax: 928-865-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24006
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: