Provider Demographics
NPI:1427264480
Name:CENTRAL MOHAVE MEDICAL CLINICS LTD
Entity type:Organization
Organization Name:CENTRAL MOHAVE MEDICAL CLINICS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTAKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-753-6668
Mailing Address - Street 1:1915 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4652
Mailing Address - Country:US
Mailing Address - Phone:928-753-6668
Mailing Address - Fax:928-753-9797
Practice Address - Street 1:1915 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4652
Practice Address - Country:US
Practice Address - Phone:928-753-6668
Practice Address - Fax:928-753-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ217209Medicaid
AZC45454Medicare UPIN
AZ217209Medicaid