Healthcare Provider Details

I. General information

NPI: 1619587508
Provider Name (Legal Business Name): DR. POOJA SHIVANANJAPPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

3100 W RAY RD STE 201
CHANDLER AZ
85226-2472
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-2920
  • Fax:
Mailing address:
  • Phone: 888-488-7640
  • Fax: 602-783-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number69619
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number69619
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: