Healthcare Provider Details

I. General information

NPI: 1093759615
Provider Name (Legal Business Name): ADOLBEN Y MONTESCLAROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5224 W DOVE CENTRE RD
MARANA AZ
85658
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-616-1445
  • Fax: 520-616-1446
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD17681
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17681
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: