Healthcare Provider Details

I. General information

NPI: 1164648226
Provider Name (Legal Business Name): LATA KUMARASWAMY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 W BELL RD STE 130
GLENDALE AZ
85308-3896
US

IV. Provider business mailing address

6220 W BELL RD STE 130
GLENDALE AZ
85308-3896
US

V. Phone/Fax

Practice location:
  • Phone: 602-547-7348
  • Fax:
Mailing address:
  • Phone: 602-547-7348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number005374
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: