Provider Demographics
NPI:1033622626
Name:AGAVE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:AGAVE MEDICAL GROUP PLLC
Other - Org Name:RALPH A DSILVA M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:DISILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-219-6631
Mailing Address - Street 1:2925 EAST RIGGS RD SUITE 8 PMB 179
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3600
Mailing Address - Country:US
Mailing Address - Phone:480-219-6631
Mailing Address - Fax:480-247-3251
Practice Address - Street 1:1301 S. CRIMAON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2737
Practice Address - Country:US
Practice Address - Phone:480-219-6631
Practice Address - Fax:480-247-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36884208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty