Healthcare Provider Details

I. General information

NPI: 1801902143
Provider Name (Legal Business Name): WALTER RIOS-CORUJO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7734 N 59TH AVE
GLENDALE AZ
85301-7816
US

IV. Provider business mailing address

1533 E WILLETTA ST
PHOENIX AZ
85006-2935
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-3999
  • Fax:
Mailing address:
  • Phone: 602-569-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number075099
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14923
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65179
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: