Provider Demographics
NPI:1619402609
Name:LEON VELARDE CARRENO, ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:LEON VELARDE CARRENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 E CAMELBACK RD STE 180
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2396
Mailing Address - Country:US
Mailing Address - Phone:602-997-0484
Mailing Address - Fax:602-943-1453
Practice Address - Street 1:2771 SILVER CREEK RD STE 120
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8023
Practice Address - Country:US
Practice Address - Phone:928-763-7722
Practice Address - Fax:928-763-7744
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-07-14
Deactivation Date:2017-11-29
Deactivation Code:
Reactivation Date:2018-10-04
Provider Licenses
StateLicense IDTaxonomies
AZ64329207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124036Medicaid