Healthcare Provider Details

I. General information

NPI: 1700373180
Provider Name (Legal Business Name): COOLIDGE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 W CENTRAL AVE STE B
COOLIDGE AZ
85128-4726
US

IV. Provider business mailing address

22707 S ELLSWORTH RD STE H101
QUEEN CREEK AZ
85142-7568
US

V. Phone/Fax

Practice location:
  • Phone: 480-792-9200
  • Fax: 480-792-9206
Mailing address:
  • Phone: 480-792-9200
  • Fax: 480-792-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43623
License Number StateAZ

VIII. Authorized Official

Name: EMILIA GOMEZ-VIEYTEZ
Title or Position: CEO
Credential: MD
Phone: 480-792-9200