Basic Information
| Provider Information | |||||||||
| NPI: | 1801951116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | URIBE | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 N 3RD AVE # 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024069449 | ||||||||
| FaxNumber: | 6022944485 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 N 3RD AVE # 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024069449 | ||||||||
| FaxNumber: | 6022944485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | ME 86557 | FL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 53935 | AZ | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 258858 | 05 | AZ | MEDICAID |