Healthcare Provider Details

I. General information

NPI: 1760645667
Provider Name (Legal Business Name): PRIYA VANNARATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 E BASELINE RD
PHOENIX AZ
85042-6551
US

IV. Provider business mailing address

2702 N 3RD ST SUITE 4020
PHOENIX AZ
85004-1130
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax: 602-243-1235
Mailing address:
  • Phone: 602-323-3345
  • Fax: 602-323-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number533339
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPENDING
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: