Healthcare Provider Details

I. General information

NPI: 1427152164
Provider Name (Legal Business Name): PEDIATRAS ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 E OSBORN RD SUITE 3
PHOENIX AZ
85016-7146
US

IV. Provider business mailing address

PO BOX 71608
PHOENIX AZ
85050-1011
US

V. Phone/Fax

Practice location:
  • Phone: 602-218-6397
  • Fax: 602-281-6391
Mailing address:
  • Phone: 602-218-6397
  • Fax: 602-281-6391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN C LLUSCO
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 602-218-6397