Basic Information
| Provider Information | |||||||||
| NPI: | 1447206966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISLAS | ||||||||
| FirstName: | MARIO-LUIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 872104 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852872104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8096570054 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 451 E UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852815390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809653349 | ||||||||
| FaxNumber: | 4809652269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27281 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.