Healthcare Provider Details

I. General information

NPI: 1396056131
Provider Name (Legal Business Name): ALLERY AND ASTHMA CENTER OF ARIZONA PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E RAY RD 101
GILBERT AZ
85296-4200
US

IV. Provider business mailing address

633 E RAY RD 101
GILBERT AZ
85296-4200
US

V. Phone/Fax

Practice location:
  • Phone: 480-855-0664
  • Fax: 480-222-4684
Mailing address:
  • Phone: 480-855-0664
  • Fax: 480-222-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number43123
License Number StateAZ

VIII. Authorized Official

Name: RAO RAJ KOSARAJU
Title or Position: OWNER
Credential: MD
Phone: 480-855-0664