Healthcare Provider Details

I. General information

NPI: 1720298409
Provider Name (Legal Business Name): DESERT CANYON PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST SUITE B 120
PHOENIX AZ
85032-3345
US

IV. Provider business mailing address

16601 N 40TH ST SUITE B 120
PHOENIX AZ
85032-3345
US

V. Phone/Fax

Practice location:
  • Phone: 602-923-7730
  • Fax: 602-923-7833
Mailing address:
  • Phone: 602-923-7730
  • Fax: 602-923-7833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERNEST J DORAME
Title or Position: OWNER
Credential: MD
Phone: 602-923-7730