Healthcare Provider Details

I. General information

NPI: 1538192703
Provider Name (Legal Business Name): SATHYA G JYOTHINAGARAM M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E MCDOWELL RD FL 3
PHOENIX AZ
85006-2502
US

IV. Provider business mailing address

925 E MCDOWELL RD FL 3
PHOENIX AZ
85006-2502
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-5895
  • Fax: 602-839-0589
Mailing address:
  • Phone: 602-839-5895
  • Fax: 602-839-0589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number58662
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number48182
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: