Provider Demographics
NPI:1154543650
Name:OCOTILLO INTERNAL MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:OCOTILLO INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HACKENYOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-895-5870
Mailing Address - Street 1:245 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6577
Mailing Address - Country:US
Mailing Address - Phone:480-895-5870
Mailing Address - Fax:480-895-0573
Practice Address - Street 1:245 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6577
Practice Address - Country:US
Practice Address - Phone:480-895-5870
Practice Address - Fax:480-895-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ79712Medicare ID - Type UnspecifiedGROUP ID#