Healthcare Provider Details

I. General information

NPI: 1124019575
Provider Name (Legal Business Name): SIVAKAMI BRENDA MOORTHY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: S BRENDA MOORTHY DO

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD E351
GLENDALE AZ
85306-4641
US

IV. Provider business mailing address

5757 W THUNDERBIRD RD E351
GLENDALE AZ
85306-4641
US

V. Phone/Fax

Practice location:
  • Phone: 602-374-3440
  • Fax: 602-374-3441
Mailing address:
  • Phone: 602-374-3440
  • Fax: 602-374-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number4264
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: