=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417966607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN MARIE DUERKSEN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 11/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5979 E GRANT RD SUITE 115
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-751-8030
-----------------------------------------------------
Fax | 520-751-0990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5979 E GRANT RD SUITE 115
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-751-8030
-----------------------------------------------------
Fax | 520-751-0990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0200X
-----------------------------------------------------
Taxonomy Name | Ophthalmic Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | 21767
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------