Provider Demographics
NPI:1669426565
Name:ESTRELLA INTERNAL MEDICINE AND PEDIATRICS PC
Entity type:Organization
Organization Name:ESTRELLA INTERNAL MEDICINE AND PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-535-5599
Mailing Address - Street 1:14541 W INDIAN SCHOOL ROAD
Mailing Address - Street 2:STE 600
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9243
Mailing Address - Country:US
Mailing Address - Phone:623-535-5599
Mailing Address - Fax:623-535-4696
Practice Address - Street 1:14541 W INDIAN SCHOOL ROAD
Practice Address - Street 2:STE 600
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9243
Practice Address - Country:US
Practice Address - Phone:623-535-5599
Practice Address - Fax:623-535-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ332481Medicaid
AZZ79088Medicare PIN