Healthcare Provider Details

I. General information

NPI: 1629571146
Provider Name (Legal Business Name): MARIELA CRISTINA CUEBAS FANTAUZZI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2018
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13995 W STATLER BLVD STE 200
SURPRISE AZ
85374-5503
US

IV. Provider business mailing address

13995 W STATLER BLVD STE 200
SURPRISE AZ
85374-5503
US

V. Phone/Fax

Practice location:
  • Phone: 602-478-3100
  • Fax:
Mailing address:
  • Phone: 602-478-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR82401
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23562
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6065629
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: