Basic Information
| Provider Information | |||||||||
| NPI: | 1720298409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT CANYON PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16601 N 40TH ST | ||||||||
| Address2: | SUITE B 120 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850323345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029237730 | ||||||||
| FaxNumber: | 6029237833 | ||||||||
| Practice Location | |||||||||
| Address1: | 16601 N 40TH ST | ||||||||
| Address2: | SUITE B 120 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850323345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029237730 | ||||||||
| FaxNumber: | 6029237833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DORAME | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6029237730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.