Healthcare Provider Details

I. General information

NPI: 1750355970
Provider Name (Legal Business Name): PALO VERDE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S VAL VISTA DR
GILBERT AZ
85296-1370
US

IV. Provider business mailing address

120 S VAL VISTA DR
GILBERT AZ
85296-1370
US

V. Phone/Fax

Practice location:
  • Phone: 480-733-6500
  • Fax: 480-633-3794
Mailing address:
  • Phone: 480-733-6500
  • Fax: 480-633-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15804
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK WILLIAM DEARDORFF
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 480-733-6500