Healthcare Provider Details

I. General information

NPI: 1689644296
Provider Name (Legal Business Name): ALFONSO SALAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7734 N 59TH AVE
GLENDALE AZ
85301-7816
US

IV. Provider business mailing address

7734 N 59TH AVE
GLENDALE AZ
85301-7816
US

V. Phone/Fax

Practice location:
  • Phone: 623-931-2444
  • Fax: 623-931-1099
Mailing address:
  • Phone: 623-931-2444
  • Fax: 623-931-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30202
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: