Healthcare Provider Details

I. General information

NPI: 1487919155
Provider Name (Legal Business Name): TRENTON ROSS HUBBARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 N CENTRAL AVE
PHOENIX AZ
85004-1455
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-6100
  • Fax: 602-933-2422
Mailing address:
  • Phone: 602-933-3124
  • Fax: 559-353-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125062383
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA167536
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberA167536
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number73222
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: