Healthcare Provider Details

I. General information

NPI: 1417929753
Provider Name (Legal Business Name): BURT A STANGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 N MASTICK WAY
NOGALES AZ
85621-1063
US

IV. Provider business mailing address

PO BOX 87812
TUCSON AZ
85754-7812
US

V. Phone/Fax

Practice location:
  • Phone: 520-375-6007
  • Fax:
Mailing address:
  • Phone: 520-743-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number33756
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32693
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: