Healthcare Provider Details

I. General information

NPI: 1790742682
Provider Name (Legal Business Name): RADHIKA VATTIKUTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15640 N 28TH DR
PHOENIX AZ
85053-4059
US

IV. Provider business mailing address

15640 N 28TH DR
PHOENIX AZ
85053-4059
US

V. Phone/Fax

Practice location:
  • Phone: 602-439-9000
  • Fax: 602-978-5233
Mailing address:
  • Phone: 602-439-9000
  • Fax: 602-978-5233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number34270
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: