Healthcare Provider Details

I. General information

NPI: 1649825282
Provider Name (Legal Business Name): STARLIGHT PEDIATRIC PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N IVY LOOP
CASA GRANDE AZ
85122-5406
US

IV. Provider business mailing address

1215 N IVY LOOP
CASA GRANDE AZ
85122-5406
US

V. Phone/Fax

Practice location:
  • Phone: 520-510-0087
  • Fax: 480-821-9555
Mailing address:
  • Phone: 520-510-0087
  • Fax: 480-821-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ADEBAYO O ATOLAGBE
Title or Position: PARTNER
Credential: MD
Phone: 205-100-0875