Healthcare Provider Details

I. General information

NPI: 1376528976
Provider Name (Legal Business Name): WESTSIDE EAR NOSE & THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD SUITE W301
GLENDALE AZ
85306-4641
US

IV. Provider business mailing address

5757 W THUNDERBIRD RD SUITE W301
GLENDALE AZ
85306-4641
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3777
  • Fax: 602-547-0379
Mailing address:
  • Phone: 602-938-3777
  • Fax: 602-547-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number28376
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number17587
License Number StateAZ

VIII. Authorized Official

Name: SUDHIR P AGARWAL
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 602-938-3777