Provider Demographics
NPI:1114201290
Name:O.SERRANO, M.D. PLLC
Entity Type:Organization
Organization Name:O.SERRANO, M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWAGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-461-1135
Mailing Address - Street 1:PO BOX 5027
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-5027
Mailing Address - Country:US
Mailing Address - Phone:480-461-1135
Mailing Address - Fax:480-461-1138
Practice Address - Street 1:37100 N GANTZEL RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7349
Practice Address - Country:US
Practice Address - Phone:480-461-1135
Practice Address - Fax:480-461-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29877207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ639396Medicaid
AZH56788Medicare UPIN
AZZ146331Medicare PIN