Healthcare Provider Details

I. General information

NPI: 1447206966
Provider Name (Legal Business Name): MARIO-LUIS ISLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 E UNIVERSITY DR
TEMPE AZ
85281-5390
US

IV. Provider business mailing address

PO BOX 872104
TEMPE AZ
85287-2104
US

V. Phone/Fax

Practice location:
  • Phone: 480-965-3349
  • Fax: 480-965-2269
Mailing address:
  • Phone: 809-657-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27281
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: