Healthcare Provider Details

I. General information

NPI: 1649806019
Provider Name (Legal Business Name): AISHWARYA SUBRAMANIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22202 N CAVE CREEK RD
PHOENIX AZ
85024-7599
US

IV. Provider business mailing address

1675 E MORTEN AVE UNIT 2139
PHOENIX AZ
85020-4687
US

V. Phone/Fax

Practice location:
  • Phone: 480-616-2222
  • Fax:
Mailing address:
  • Phone: 813-728-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011043
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: