Healthcare Provider Details

I. General information

NPI: 1669464210
Provider Name (Legal Business Name): JUAN LLUSCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/10/2006

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: 480-206-7319
  • Fax:
Mailing address:
  • Phone: 480-206-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAZ31758
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: