Healthcare Provider Details

I. General information

NPI: 1861506230
Provider Name (Legal Business Name): RAJIV KWATRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 N 7TH ST SUITE 290
PHOENIX AZ
85006-2754
US

IV. Provider business mailing address

1331 N 7TH ST SUITE 290
PHOENIX AZ
85006-2754
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-6744
  • Fax: 602-230-6746
Mailing address:
  • Phone: 602-230-6744
  • Fax: 602-230-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25383
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number25383
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25383
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: