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NPI Code Detail

MEDICARE: NURUL ITQIYAH HARIADI MD

MEDICARE: NURUL ITQIYAH HARIADI MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician4301090456MI

General Provider Information

NPI Number : 1881875037
Entity Type Code : Individual
Provider Name (Legal Business Name) : NURUL ITQIYAH HARIADI MD
Provider Business Mailing Address
First Line : 17900 N PORTER RD
Second Line :
City : MARICOPA
State : AZ
Zip : 85138-4228
Country : US
Telephone Number : 520-233-2500
Fax Number : 520-233-2574
Provider Business Practice Location Address
First Line : 17900 N PORTER RD
Second Line :
City : MARICOPA
State : AZ
Zip : 85138-4228
Country : US
Telephone Number : 520-233-2500
Fax Number : 520-233-2574
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2007
Last Update Date : 07/22/2016

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