Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 0420005828 | VT |
NPI | 1013091446 |
---|---|
Provider Name | Dr. Ottfried Vonwaldenburg |
First Address | Tucson, AZ 85746-7012 |
Second Address | Tucson, AZ 85746-7012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
850471 | (05) | AZ |
B85641 | (02) | AZ |