Healthcare Provider Details

I. General information

NPI: 1124014196
Provider Name (Legal Business Name): ELIAS OMAR RUILOBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: E OMAR RUILOBA

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20950 N TATUM BLVD STE 380
PHOENIX AZ
85050-4258
US

IV. Provider business mailing address

20950 N TATUM BLVD STE 380
PHOENIX AZ
85050-4258
US

V. Phone/Fax

Practice location:
  • Phone: 480-626-7584
  • Fax: 480-210-0230
Mailing address:
  • Phone: 480-626-7584
  • Fax: 480-210-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25458
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: