Provider Demographics
NPI:1699161190
Name:PACHECO CANO, CARLOS ISAAC (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ISAAC
Last Name:PACHECO CANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:155 CALLE PORTAL STE 300
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ55327207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ469822Medicaid