Healthcare Provider Details

I. General information

NPI: 1689106809
Provider Name (Legal Business Name): MALTI BHAMRAH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13606 N 59TH AVE STE 1
GLENDALE AZ
85304-1271
US

IV. Provider business mailing address

13606 N 59TH AVE STE 1
GLENDALE AZ
85304-1271
US

V. Phone/Fax

Practice location:
  • Phone: 602-889-1099
  • Fax:
Mailing address:
  • Phone: 602-978-6100
  • Fax: 602-978-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number010660
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: