Provider Demographics
NPI:1023260692
Name:AGAVE PODIATRY, LLC
Entity type:Organization
Organization Name:AGAVE PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-231-6231
Mailing Address - Street 1:3650 S TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-2672
Mailing Address - Country:US
Mailing Address - Phone:480-231-6231
Mailing Address - Fax:480-883-0246
Practice Address - Street 1:10440 E RIGGS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7751
Practice Address - Country:US
Practice Address - Phone:480-895-7600
Practice Address - Fax:480-895-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0582213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty