Healthcare Provider Details

I. General information

NPI: 1689676256
Provider Name (Legal Business Name): AHWATUKEE PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15715 S 46TH ST SUITE 102
PHOENIX AZ
85048-0438
US

IV. Provider business mailing address

15715 S 46TH ST SUITE 102
PHOENIX AZ
85048-0438
US

V. Phone/Fax

Practice location:
  • Phone: 480-496-6444
  • Fax: 480-496-9688
Mailing address:
  • Phone: 480-496-6444
  • Fax: 480-496-9688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2633
License Number StateAZ

VIII. Authorized Official

Name: DR. MARY JO FOA KUTLER
Title or Position: PRESIDENT
Credential: DO
Phone: 480-496-6444