Basic Information
| Provider Information | |||||||||
| NPI: | 1578504940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESTRELLA PEDIATRICS P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9520 W PALM LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233883216 | ||||||||
| FaxNumber: | 6233884902 | ||||||||
| Practice Location | |||||||||
| Address1: | 9520 W PALM LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233883216 | ||||||||
| FaxNumber: | 6233884902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6233883216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 628133 | 05 | AZ | MEDICAID |