Basic Information
| Provider Information | |||||||||
| NPI: | 1487751947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAX | ||||||||
| FirstName: | DANIELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E ELVIRA RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857567124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206266508 | ||||||||
| FaxNumber: | 5206266571 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 N WILMOT RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206949988 | ||||||||
| FaxNumber: | 5206949917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 17936 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 280488 | 05 | AZ | MEDICAID |