Healthcare Provider Details

I. General information

NPI: 1043461171
Provider Name (Legal Business Name): DESERT KIDS PEDIATRICS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 N 19TH AVE STE 109
PHOENIX AZ
85015-1105
US

IV. Provider business mailing address

6707 N 19TH AVE STE 109
PHOENIX AZ
85015-1105
US

V. Phone/Fax

Practice location:
  • Phone: 602-973-9234
  • Fax: 602-973-9271
Mailing address:
  • Phone: 602-973-9234
  • Fax: 602-973-9271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28558
License Number StateAZ

VIII. Authorized Official

Name: GRAVIOLA R. BROOKS-MARTINEZ
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 602-973-9234