Healthcare Provider Details

I. General information

NPI: 1568667947
Provider Name (Legal Business Name): ITORO ELIJAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 N CENTRAL AVE STE 160
PHOENIX AZ
85012-2702
US

IV. Provider business mailing address

2901 N CENTRAL AVE STE 160
PHOENIX AZ
85012-2702
US

V. Phone/Fax

Practice location:
  • Phone: 602-747-4000
  • Fax:
Mailing address:
  • Phone: 602-747-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number46474
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: