Healthcare Provider Details

I. General information

NPI: 1265554612
Provider Name (Legal Business Name): THE PEDIATRIC ENDOCRINE DIABETES CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W THOMAS RD SUITE 201
PHOENIX AZ
85013-4417
US

IV. Provider business mailing address

333 W THOMAS RD SUITE 201
PHOENIX AZ
85013-4417
US

V. Phone/Fax

Practice location:
  • Phone: 602-692-7926
  • Fax: 602-266-9660
Mailing address:
  • Phone: 602-692-7926
  • Fax: 602-266-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number30355
License Number StateAZ

VIII. Authorized Official

Name: DR. MAHMOUD B KABBANI
Title or Position: PEDIATRIC ENDOCRINE
Credential: MD
Phone: 602-692-7926