Provider Demographics
NPI:1215337381
Name:EL DORADO PROSTATE CENTER, PC
Entity type:Organization
Organization Name:EL DORADO PROSTATE CENTER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-403-7727
Mailing Address - Street 1:PO BOX 98820
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8820
Mailing Address - Country:US
Mailing Address - Phone:602-441-9520
Mailing Address - Fax:
Practice Address - Street 1:1100 N EL DORADO PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4606
Practice Address - Country:US
Practice Address - Phone:480-265-2797
Practice Address - Fax:602-441-9524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21528208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty