Healthcare Provider Details

I. General information

NPI: 1578381158
Provider Name (Legal Business Name): XPRESS NEURODIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 E LOUISE DR
PHOENIX AZ
85050-8314
US

IV. Provider business mailing address

12409 W INDIAN SCHOOL RD STE A108
AVONDALE AZ
85392-9503
US

V. Phone/Fax

Practice location:
  • Phone: 623-328-7087
  • Fax:
Mailing address:
  • Phone: 623-238-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AZIZ MALLIK
Title or Position: MEMBER
Credential:
Phone: 623-238-3889