Healthcare Provider Details

I. General information

NPI: 1013984970
Provider Name (Legal Business Name): THIMMAVAJJHALA SREECHARANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13260 N 94TH DR SUITE 101
PEORIA AZ
85381-4828
US

IV. Provider business mailing address

PO BOX 5336
PEORIA AZ
85385-5336
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-2732
  • Fax: 623-972-1323
Mailing address:
  • Phone: 623-933-2732
  • Fax: 623-972-1323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number19302
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: