Organization
LAKE HAVASU OB/GYN, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARY JO VITA URSO D.O. (OWNER)
(928) 680-2846
Entity
Organization
Contact information
Practice address
99 RIVIERA DR, LAKE HAVASU CITY, AZ 86403-5713
(928) 680-2846
(928) 680-2845
Mailing address
99 RIVIERA DR, LAKE HAVASU CITY, AZ 86403-5713
(928) 680-2846
(928) 680-2845
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
20A8265
CA
261QM2500X
Medical Specialty Clinic/Center
Primary
3696
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
434157
—
AZ
Enumeration date
11/02/2007
Last updated
02/29/2012
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