Provider Demographics
NPI:1699918763
Name:PROSTATE DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:PROSTATE DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LERER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-8001
Mailing Address - Street 1:4245 E DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9204
Mailing Address - Country:US
Mailing Address - Phone:602-788-7814
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST
Practice Address - Street 2:SUITE 222
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3345
Practice Address - Country:US
Practice Address - Phone:602-368-8001
Practice Address - Fax:602-368-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D1098706291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory