Provider Demographics
NPI:1346335676
Name:PHOENIX GERIATRICS AND INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:PHOENIX GERIATRICS AND INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:602-770-2468
Mailing Address - Street 1:PO BOX 28757
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-0162
Mailing Address - Country:US
Mailing Address - Phone:602-770-2468
Mailing Address - Fax:480-409-2512
Practice Address - Street 1:8300 E DIXILETA DR
Practice Address - Street 2:#278
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85266-2273
Practice Address - Country:US
Practice Address - Phone:602-770-2468
Practice Address - Fax:480-409-2512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15447207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ101442Medicare PIN