Basic Information
| Provider Information | |||||||||
| NPI: | 1578544987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALLARES | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865040649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298000 | ||||||||
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| Practice Location | |||||||||
| Address1: | CORNER ROUTE N12 AND N7 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | F8602 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME87312 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 110390504 | 05 | TX | MEDICAID | 110390505 | 05 | TX | MEDICAID |