Healthcare Provider Details

I. General information

NPI: 1083603955
Provider Name (Legal Business Name): KERAMAT BEHSHAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 03/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 N 19TH AVE
PHOENIX AZ
85015-2432
US

IV. Provider business mailing address

5720 N 19TH AVE
PHOENIX AZ
85015-2432
US

V. Phone/Fax

Practice location:
  • Phone: 602-864-0211
  • Fax: 602-864-9392
Mailing address:
  • Phone: 602-864-0211
  • Fax: 602-864-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20101
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: