=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952425951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUMBERTO M RENDON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4129 E INDIAN SCHOOL RD APT 422
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-5388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-418-5669
-----------------------------------------------------
Fax | 602-314-5729
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4129 E INDIAN SCHOOL RD APT 422
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-5388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-418-5669
-----------------------------------------------------
Fax | 602-314-5729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 16214
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------