Provider Demographics
NPI:1639125511
Name:ESTRELLA INTERNAL MEDICINE & GERIATRICS CLINIC, PLC
Entity Type:Organization
Organization Name:ESTRELLA INTERNAL MEDICINE & GERIATRICS CLINIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:MAGAT
Authorized Official - Last Name:GREGORIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-873-1500
Mailing Address - Street 1:8410 W THOMAS RD
Mailing Address - Street 2:BLDG. 2, SUITE 112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3329
Mailing Address - Country:US
Mailing Address - Phone:623-873-1500
Mailing Address - Fax:623-873-4247
Practice Address - Street 1:8410 W THOMAS RD
Practice Address - Street 2:BLDG. 2, SUITE 112
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3329
Practice Address - Country:US
Practice Address - Phone:623-873-1500
Practice Address - Fax:623-873-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0300X, 261QP2300X
AZ27047261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ111092OtherMEDICARE ID - TYPE UNSPECIFIED
AZZ111092OtherMEDICARE ID - TYPE UNSPECIFIED