Basic Information
| Provider Information | |||||||||
| NPI: | 1669426565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESTRELLA INTERNAL MEDICINE AND PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14541 W INDIAN SCHOOL ROAD | ||||||||
| Address2: | STE 600 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853389243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235355599 | ||||||||
| FaxNumber: | 6235354696 | ||||||||
| Practice Location | |||||||||
| Address1: | 14541 W INDIAN SCHOOL ROAD | ||||||||
| Address2: | STE 600 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853389243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235355599 | ||||||||
| FaxNumber: | 6235354696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 11/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6235355599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 332481 | 05 | AZ | MEDICAID |