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General NPI Number Information
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NPI Number | 1649825282
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Entity Type | Organization
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Legal Business Name | STARLIGHT PEDIATRIC PRIMARY CARE PLLC
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Dates
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Enumeration Date | 08/08/2019
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Last Update Date | 09/25/2019
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Provider Practice Location Address
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Address Line | 1215 N IVY LOOP
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City | CASA GRANDE
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State | AZ
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Zip | 85122-5406
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Country | US
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Telephone | 520-510-0087
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Fax | 480-821-9555
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Provider Business Mailing Address
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Address Line | 1215 N IVY LOOP
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City | CASA GRANDE
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State | AZ
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Zip | 85122-5406
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Country | US
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Telephone | 520-510-0087
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Fax | 480-821-9555
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Authorized Official
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Title or Position | PARTNER
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Name | ADEBAYO O ATOLAGBE
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Credential | MD
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Telephone | 205-100-0875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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