Provider Demographics
NPI:1386866929
Name:PRISTO, LARRY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:PRISTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28150 N ALMA SCHOOL PKWY
Mailing Address - Street 2:SUITE 103 - 500
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-8048
Mailing Address - Country:US
Mailing Address - Phone:480-443-4285
Mailing Address - Fax:
Practice Address - Street 1:4650 W. SWEETWATER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1505
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ641251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ562539Medicaid