Healthcare Provider Details

I. General information

NPI: 1083892319
Provider Name (Legal Business Name): ESTRELLA MOUNTAIN FOOT & ANKLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N CENTRAL BLVD #4
QUARTZSIDE AZ
85346
US

IV. Provider business mailing address

13065 W MCDOWELL RD STE A103
AVONDALE AZ
85392-6439
US

V. Phone/Fax

Practice location:
  • Phone: 928-927-6105
  • Fax:
Mailing address:
  • Phone: 623-547-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0580
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0607
License Number StateAZ

VIII. Authorized Official

Name: DR. LAUREL ROBISON
Title or Position: PRESIDENT
Credential: DPM
Phone: 623-547-2800