Healthcare Provider Details

I. General information

NPI: 1164287124
Provider Name (Legal Business Name): AMERICAN FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N 19TH AVE STE 218
PHOENIX AZ
85015-2452
US

IV. Provider business mailing address

1514 W THOMAS RD
PHOENIX AZ
85015-6101
US

V. Phone/Fax

Practice location:
  • Phone: 602-413-0431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALEJANDRO E LOPEZ
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 832-454-9989