Provider Demographics
NPI:1790798072
Name:PUEBLO FAMILY PHYSICIANS LTD
Entity Type:Organization
Organization Name:PUEBLO FAMILY PHYSICIANS LTD
Other - Org Name:PUEBLO FAMILY PHYSICIANS LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-850-8913
Mailing Address - Street 1:4350 N 19TH AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4602
Mailing Address - Country:US
Mailing Address - Phone:602-850-8913
Mailing Address - Fax:602-532-2956
Practice Address - Street 1:4350 N 19TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4602
Practice Address - Country:US
Practice Address - Phone:602-264-9191
Practice Address - Fax:602-532-2973
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO FAMILY PHYSICIANS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-15
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ423779Medicaid
AZC99012Medicare UPIN
AZZWCHTQMedicare PIN