Healthcare Provider Details

I. General information

NPI: 1841813656
Provider Name (Legal Business Name): WEIGHT LOSS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DR STE D-3
PEORIA AZ
85381-4836
US

IV. Provider business mailing address

20340 N LAKE PLEASANT RD STE 109
PEORIA AZ
85382-9713
US

V. Phone/Fax

Practice location:
  • Phone: 623-230-2912
  • Fax:
Mailing address:
  • Phone: 623-299-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SEETHALAKSHMI MAHADEVAN
Title or Position: OWNER
Credential:
Phone: 480-277-3867