Basic Information
Provider Information | |||||||||
NPI: | 1356859128 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLEASANT PEDIATRICS PLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9059 W LAKE PLEASANT PKWY STE E540 | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853828396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233223380 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10180 W HAPPY VALLEY PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853831389 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233223380 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2018 | ||||||||
LastUpdateDate: | 10/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAVI | ||||||||
AuthorizedOfficialFirstName: | PRASAD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6233223380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PLEASANT PEDIATRICS PLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 34320 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 645732 | 05 | AZ |   | MEDICAID |