Healthcare Provider Details

I. General information

NPI: 1568643229
Provider Name (Legal Business Name): OLD PUEBLO CARDIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 E FORT LOWELL RD SUITE 113
TUCSON AZ
85712-1041
US

IV. Provider business mailing address

PO BOX 64086
TUCSON AZ
85728-4086
US

V. Phone/Fax

Practice location:
  • Phone: 520-323-7277
  • Fax: 520-881-1968
Mailing address:
  • Phone: 520-323-7277
  • Fax: 520-881-1968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEE GOLDBERG
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 520-323-7277