Healthcare Provider Details

I. General information

NPI: 1841287836
Provider Name (Legal Business Name): CHILDREN'S DOCTOR, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/25/2022
Certification Date: 12/25/2022
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: DR. KERAMAT BEHSHAD
Title or Position: PRESIDENT
Credential: M.D
Phone: 602-864-0211