Healthcare Provider Details

I. General information

NPI: 1790798072
Provider Name (Legal Business Name): PUEBLO FAMILY PHYSICIANS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 N 19TH AVE SUITE 6
PHOENIX AZ
85015-4602
US

IV. Provider business mailing address

4350 N 19TH AVE STE 6
PHOENIX AZ
85015-4602
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-9191
  • Fax: 602-532-2973
Mailing address:
  • Phone: 602-850-8913
  • Fax: 602-532-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2325
License Number StateAZ

VIII. Authorized Official

Name: RICK JOHNS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 602-850-8913