Healthcare Provider Details

I. General information

NPI: 1639125511
Provider Name (Legal Business Name): ESTRELLA INTERNAL MEDICINE & GERIATRICS CLINIC, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8410 W THOMAS RD BLDG. 2, SUITE 112
PHOENIX AZ
85037-3329
US

IV. Provider business mailing address

8410 W THOMAS RD BLDG. 2, SUITE 112
PHOENIX AZ
85037-3329
US

V. Phone/Fax

Practice location:
  • Phone: 623-873-1500
  • Fax: 623-873-4247
Mailing address:
  • Phone: 623-873-1500
  • Fax: 623-873-4247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number27047
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. LUCIA MAGAT GREGORIO
Title or Position: PRESIDENT
Credential: MD
Phone: 623-873-1500