Provider Demographics
NPI:1306078514
Name:ST. LUKE'S PEDIATRICS
Entity type:Organization
Organization Name:ST. LUKE'S PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:EMILIO
Authorized Official - Last Name:DALOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-254-0200
Mailing Address - Street 1:1310 N 24TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4617
Mailing Address - Country:US
Mailing Address - Phone:602-254-0200
Mailing Address - Fax:602-254-0237
Practice Address - Street 1:1310 N 24TH ST STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4617
Practice Address - Country:US
Practice Address - Phone:602-254-0200
Practice Address - Fax:602-254-0237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA FAMILY CLINICS CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-20
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ526031Medicaid