Provider Demographics
NPI:1710139860
Name:SONORAN SKY PEDIATRICS
Entity Type:Organization
Organization Name:SONORAN SKY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:E
Authorized Official - Last Name:LETIZIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-365-0050
Mailing Address - Street 1:10720 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3810
Mailing Address - Country:US
Mailing Address - Phone:480-365-0050
Mailing Address - Fax:480-365-0049
Practice Address - Street 1:10720 E SOUTHERN AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3810
Practice Address - Country:US
Practice Address - Phone:480-365-0050
Practice Address - Fax:480-365-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ088674Medicaid
AZ383934Medicaid
AZ527283Medicaid
AZ250599Medicaid