Provider Demographics
NPI:1427152164
Name:PEDIATRAS ARIZONA
Entity type:Organization
Organization Name:PEDIATRAS ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LLUSCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-218-6397
Mailing Address - Street 1:PO BOX 71608
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-1011
Mailing Address - Country:US
Mailing Address - Phone:602-218-6397
Mailing Address - Fax:602-281-6391
Practice Address - Street 1:1641 E OSBORN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7146
Practice Address - Country:US
Practice Address - Phone:602-218-6397
Practice Address - Fax:602-281-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
805872OtherAHCCCS