Provider Demographics
NPI:1851056873
Name:LA GROTTA, RICARDO (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:LA GROTTA
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 1:840 E MCKELLIPS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-9654
Mailing Address - Country:US
Mailing Address - Phone:602-491-0703
Mailing Address - Fax:
Practice Address - Street 1:3200 N DOBSON RD STE B-1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9608
Practice Address - Country:US
Practice Address - Phone:602-491-0703
Practice Address - Fax:833-464-2516
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70920207Q00000X
PR022884208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice