Healthcare Provider Details

I. General information

NPI: 1063702934
Provider Name (Legal Business Name): 1ST CARE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S WATSON RD STE 104
BUCKEYE AZ
85326-6264
US

IV. Provider business mailing address

PO BOX 11528
GOODYEAR AZ
85318
US

V. Phone/Fax

Practice location:
  • Phone: 623-251-3201
  • Fax: 623-251-3205
Mailing address:
  • Phone: 623-251-3201
  • Fax: 623-251-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38055
License Number StateAZ

VIII. Authorized Official

Name: SULTAN MOHAMMAD
Title or Position: OWNER
Credential: MD
Phone: 623-251-3201