Healthcare Provider Details

I. General information

NPI: 1881663441
Provider Name (Legal Business Name): KOJASTEH MAHSA GHAZIASKAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6142 E BROWN RD 102
MESA AZ
85205-4962
US

IV. Provider business mailing address

6142 E BROWN RD 102
MESA AZ
85205-4962
US

V. Phone/Fax

Practice location:
  • Phone: 480-396-2087
  • Fax: 480-396-3973
Mailing address:
  • Phone: 480-396-2087
  • Fax: 480-396-3973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34309
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: