Healthcare Provider Details

I. General information

NPI: 1861624793
Provider Name (Legal Business Name): SAN TAN MOUNTAIN PEDIATRICS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S LINDSAY RD STE 110
GILBERT AZ
85297-1504
US

IV. Provider business mailing address

PO BOX 6443
CHANDLER AZ
85246-6443
US

V. Phone/Fax

Practice location:
  • Phone: 480-659-5811
  • Fax:
Mailing address:
  • Phone: 480-659-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29688
License Number StateAZ

VIII. Authorized Official

Name: CINDY DUKE
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 480-659-5811