Healthcare Provider Details

I. General information

NPI: 1467567883
Provider Name (Legal Business Name): RAJESH PRAFUL DAULAT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE J171-172
GLENDALE AZ
85306-3732
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD J171/ J172
GLENDALE AZ
85306-3709
US

V. Phone/Fax

Practice location:
  • Phone: 623-977-6245
  • Fax: 623-977-6280
Mailing address:
  • Phone: 623-977-6245
  • Fax: 623-977-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0547
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: