Provider Demographics
NPI:1952623100
Name:ESTRELLA EAR, NOSE AND THROAT PC
Entity Type:Organization
Organization Name:ESTRELLA EAR, NOSE AND THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIGGENHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-535-8770
Mailing Address - Street 1:PO BOX 12250
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4013
Mailing Address - Country:US
Mailing Address - Phone:623-535-8770
Mailing Address - Fax:623-535-8771
Practice Address - Street 1:2700 N 140TH AVE
Practice Address - Street 2:STE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-535-8770
Practice Address - Fax:623-535-8771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ497110Medicaid
AZ497110Medicaid