Provider Demographics
NPI:1891850145
Name:CACTUS CHILDRENS CLINIC PC
Entity type:Organization
Organization Name:CACTUS CHILDRENS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-978-2500
Mailing Address - Street 1:5940 W UNION HILLS DR
Mailing Address - Street 2:SUITE D-100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1308
Mailing Address - Country:US
Mailing Address - Phone:602-978-2500
Mailing Address - Fax:602-938-2198
Practice Address - Street 1:5940 W UNION HILLS DR
Practice Address - Street 2:SUITE D-100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1308
Practice Address - Country:US
Practice Address - Phone:602-978-2500
Practice Address - Fax:602-938-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32657208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ215112001Medicaid