Healthcare Provider Details

I. General information

NPI: 1508569286
Provider Name (Legal Business Name): RALDON BLAKE ALLRED DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 W MCDOWELL RD
GOODYEAR AZ
85395-2635
US

IV. Provider business mailing address

1040 E 900 S UNIT 19
ST GEORGE UT
84790-2045
US

V. Phone/Fax

Practice location:
  • Phone: 623-882-1500
  • Fax:
Mailing address:
  • Phone: 385-208-8649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR3958
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: