Healthcare Provider Details

I. General information

NPI: 1184958803
Provider Name (Legal Business Name): SHAHAN FERNANDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-1018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR71576
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: