Provider Demographics
NPI:1043461171
Name:DESERT KIDS PEDIATRICS PLC
Entity Type:Organization
Organization Name:DESERT KIDS PEDIATRICS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GRAVIOLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROOKS-MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-973-9234
Mailing Address - Street 1:6707 N 19TH AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1105
Mailing Address - Country:US
Mailing Address - Phone:602-973-9234
Mailing Address - Fax:602-973-9271
Practice Address - Street 1:6707 N 19TH AVE
Practice Address - Street 2:STE 109
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1105
Practice Address - Country:US
Practice Address - Phone:602-973-9234
Practice Address - Fax:602-973-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ375531Medicaid