Healthcare Provider Details

I. General information

NPI: 1558548735
Provider Name (Legal Business Name): DEEPESH M SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16390 N 59TH AVE STE 200
GLENDALE AZ
85306
US

IV. Provider business mailing address

16390 N 59TH AVE STE 200
GLENDALE AZ
85306-1711
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-4000
  • Fax: 623-334-4400
Mailing address:
  • Phone: 623-334-4000
  • Fax: 623-334-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL-225536
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number37959
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number37959
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: