Healthcare Provider Details

I. General information

NPI: 1841482577
Provider Name (Legal Business Name): YUMA UROLOGY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S ELKS LN
YUMA AZ
85364-6258
US

IV. Provider business mailing address

PO BOX 6514
YUMA AZ
85366-2522
US

V. Phone/Fax

Practice location:
  • Phone: 928-341-1900
  • Fax: 928-341-1973
Mailing address:
  • Phone: 928-257-8699
  • Fax: 928-341-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number37017
License Number StateAZ

VIII. Authorized Official

Name: DR. NATAKOM NASH CHULAMORKODT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-501-7706