Healthcare Provider Details

I. General information

NPI: 1396155461
Provider Name (Legal Business Name): JUSTIN FAMOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19646 N 27TH AVE STE 108
PHOENIX AZ
85027
US

IV. Provider business mailing address

19646 N 27TH AVE STE 108
PHOENIX AZ
85027-4025
US

V. Phone/Fax

Practice location:
  • Phone: 480-278-8300
  • Fax:
Mailing address:
  • Phone: 480-278-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number51553
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: