Healthcare Provider Details

I. General information

NPI: 1598804510
Provider Name (Legal Business Name): ENRIQUE M CIFUENTES, JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W BASELINE RD SUITE 8
TEMPE AZ
85283-1067
US

IV. Provider business mailing address

2727 W BASELINE RD SUITE 8
TEMPE AZ
85283-1068
US

V. Phone/Fax

Practice location:
  • Phone: 602-323-0904
  • Fax: 602-243-7616
Mailing address:
  • Phone: 602-323-0904
  • Fax: 602-243-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42048
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: