Provider Demographics
NPI:1164817425
Name:PALACIOS, ISAAC (DPM)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 N LADERA
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1114
Mailing Address - Country:US
Mailing Address - Phone:928-283-2501
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0803213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ97449Medicaid