Provider Demographics
NPI:1033384136
Name:DESERT CANYON FAMILY & SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:DESERT CANYON FAMILY & SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:JULIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-820-4305
Mailing Address - Street 1:3800 W RAY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5940
Mailing Address - Country:US
Mailing Address - Phone:480-820-4305
Mailing Address - Fax:480-820-5540
Practice Address - Street 1:3800 W RAY RD STE 5
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5940
Practice Address - Country:US
Practice Address - Phone:480-820-4305
Practice Address - Fax:480-820-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ443862Medicaid
AZZ66572Medicare PIN
AZ443862Medicaid