Healthcare Provider Details

I. General information

NPI: 1780780437
Provider Name (Legal Business Name): ROY KIYOHARU TERAMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1637
Mailing address:
  • Phone: 602-263-1511
  • Fax: 602-263-1637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14222
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number14222
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: