Healthcare Provider Details

I. General information

NPI: 1497322655
Provider Name (Legal Business Name): JACE BLAINE BUXTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number73484
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: