Provider Demographics
NPI:1194167858
Name:ORIGEN ORTHOPEDICS & OPTIMAL HEALTH
Entity type:Organization
Organization Name:ORIGEN ORTHOPEDICS & OPTIMAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-777-9385
Mailing Address - Street 1:7790 N ORACLE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6579
Mailing Address - Country:US
Mailing Address - Phone:520-777-9385
Mailing Address - Fax:520-306-4843
Practice Address - Street 1:7790 N ORACLE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6579
Practice Address - Country:US
Practice Address - Phone:520-777-9385
Practice Address - Fax:520-306-4843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5503208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ163651Medicare UPIN