Healthcare Provider Details

I. General information

NPI: 1235104431
Provider Name (Legal Business Name): SALLU M. JABATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 N ARIZONA AVE STE 112
CHANDLER AZ
85225-7163
US

IV. Provider business mailing address

3908 SHADOW LOCH DR
SUWANEE GA
30024-7455
US

V. Phone/Fax

Practice location:
  • Phone: 480-292-8579
  • Fax: 480-306-6029
Mailing address:
  • Phone: 678-559-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36200
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number36200
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: