Healthcare Provider Details

I. General information

NPI: 1467850461
Provider Name (Legal Business Name): PARKSIDE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 8TH ST
YUMA AZ
85364-2956
US

IV. Provider business mailing address

501 W 8TH ST
YUMA AZ
85364-2956
US

V. Phone/Fax

Practice location:
  • Phone: 928-782-9000
  • Fax:
Mailing address:
  • Phone: 928-782-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL ORTIZ
Title or Position: MEMBER
Credential: PA-C
Phone: 928-539-0055