Provider Demographics
NPI:1730133364
Name:SEVERINO, EUGENE L (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:L
Last Name:SEVERINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:L
Other - Last Name:SEVERINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-972-9590
Practice Address - Street 1:13640 N PLAZA DEL RIO BLVD
Practice Address - Street 2:STE 210
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4846
Practice Address - Country:US
Practice Address - Phone:623-876-3830
Practice Address - Fax:623-876-3934
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ246125Medicaid
AZE55257Medicare UPIN
AZ246125Medicaid
AZ10WCFGW02Medicare ID - Type UnspecifiedMDCR GRP WCFGW