Basic Information
Provider Information | |||||||||
NPI: | 1568649812 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALDERON | ||||||||
FirstName: | ROBERTO | ||||||||
MiddleName: | DANIEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3811 E BELL RD STE 309 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850322160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804200749 | ||||||||
FaxNumber: | 4804200732 | ||||||||
Practice Location | |||||||||
Address1: | 3811 E BELL RD STE 309 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804200749 | ||||||||
FaxNumber: | 4804200732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2008 | ||||||||
LastUpdateDate: | 10/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2013-00002 | NC | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 21200 | MT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 34221 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | P00817167 | 01 |   | MEDICARE RR | OTHER | P00884670 | 01 | MD | RR MEDICARE | OTHER | NCB434A | 01 | NC | MEDICARE PTAN | OTHER |