Healthcare Provider Details

I. General information

NPI: 1346335676
Provider Name (Legal Business Name): PHOENIX GERIATRICS & INTERNAL MEDICINE P L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 E DIXILETA DR #278
SCOTTSDALE AZ
85266-2273
US

IV. Provider business mailing address

PO BOX 28757
SCOTTSDALE AZ
85255-0162
US

V. Phone/Fax

Practice location:
  • Phone: 602-770-2468
  • Fax: 480-409-2512
Mailing address:
  • Phone: 602-770-2468
  • Fax: 480-409-2512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number15447
License Number StateAZ

VIII. Authorized Official

Name: LUIS L GONZALEZ JR.
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 602-770-2468