Basic Information
Provider Information | |||||||||
NPI: | 1649825282 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STARLIGHT PEDIATRIC PRIMARY CARE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1215 N IVY LOOP | ||||||||
Address2: |   | ||||||||
City: | CASA GRANDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 851225406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205100087 | ||||||||
FaxNumber: | 4808219555 | ||||||||
Practice Location | |||||||||
Address1: | 1215 N IVY LOOP | ||||||||
Address2: |   | ||||||||
City: | CASA GRANDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 851225406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205100087 | ||||||||
FaxNumber: | 4808219555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2019 | ||||||||
LastUpdateDate: | 09/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ATOLAGBE | ||||||||
AuthorizedOfficialFirstName: | ADEBAYO | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 2051000875 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.