Healthcare Provider Details

I. General information

NPI: 1669426565
Provider Name (Legal Business Name): ESTRELLA INTERNAL MEDICINE AND PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14541 W INDIAN SCHOOL ROAD STE 600
GOODYEAR AZ
85338-9243
US

IV. Provider business mailing address

14541 W INDIAN SCHOOL ROAD STE 600
GOODYEAR AZ
85338-9243
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-5599
  • Fax: 623-535-4696
Mailing address:
  • Phone: 623-535-5599
  • Fax: 623-535-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENT M JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 623-535-5599