Provider Demographics
NPI:1720298409
Name:DESERT CANYON PEDIATRICS PC
Entity Type:Organization
Organization Name:DESERT CANYON PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:J
Authorized Official - Last Name:DORAME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-923-7730
Mailing Address - Street 1:16601 N 40TH ST
Mailing Address - Street 2:SUITE B 120
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3345
Mailing Address - Country:US
Mailing Address - Phone:602-923-7730
Mailing Address - Fax:602-923-7833
Practice Address - Street 1:16601 N 40TH ST
Practice Address - Street 2:SUITE B 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3345
Practice Address - Country:US
Practice Address - Phone:602-923-7730
Practice Address - Fax:602-923-7833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID