Healthcare Provider Details

I. General information

NPI: 1003963216
Provider Name (Legal Business Name): FOOTHILL UROLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S RAYMOND AVE SUITE 220
PASADENA CA
91105-3278
US

IV. Provider business mailing address

630 S RAYMOND AVE SUITE 220
PASADENA CA
91105-3278
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-8454
  • Fax: 626-795-5631
Mailing address:
  • Phone: 626-795-8454
  • Fax: 626-795-5631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TINA M. SOTO
Title or Position: OFFICE MANAGER
Credential:
Phone: 626-795-8454