Provider Demographics
NPI:1447445440
Name:CARDENAS, JAVIER FORTUNATO (MD)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:FORTUNATO
Last Name:CARDENAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W THOMAS RD #304
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-406-4323
Mailing Address - Fax:602-406-3810
Practice Address - Street 1:222 W THOMAS RD
Practice Address - Street 2:SUITE 304
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4419
Practice Address - Country:US
Practice Address - Phone:602-406-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ810422084N0400X
AZ365792084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ259914Medicaid
AZZ130639Medicare PIN