Provider Demographics
NPI:1861412686
Name:GOLDFIELD MEDICAL CLINICS, LLC
Entity type:Organization
Organization Name:GOLDFIELD MEDICAL CLINICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-962-0101
Mailing Address - Street 1:99 S GOLD DR STE 5
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-5036
Mailing Address - Country:US
Mailing Address - Phone:480-962-0101
Mailing Address - Fax:480-962-0202
Practice Address - Street 1:7615 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2000
Practice Address - Country:US
Practice Address - Phone:480-962-0101
Practice Address - Fax:480-962-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ376592OtherAHCCCS
AZAZ 0742840OtherBC/BS
AZZ159572Medicare PIN
AZ376592OtherAHCCCS