Healthcare Provider Details

I. General information

NPI: 1457048084
Provider Name (Legal Business Name): EVA PURNA KHONDAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date: 11/27/2023
Reactivation Date: 01/04/2024

III. Provider practice location address

33 W TAMARISK ST
PHOENIX AZ
85041-2422
US

IV. Provider business mailing address

8088 W WHITNEY DR
PEORIA AZ
85345-6564
US

V. Phone/Fax

Practice location:
  • Phone: 833-855-9973
  • Fax: 605-655-9660
Mailing address:
  • Phone: 402-552-3222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number78980
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: