Healthcare Provider Details

I. General information

NPI: 1053458216
Provider Name (Legal Business Name): STEFAN SHAHRAM NAWAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax: 602-222-2723
Mailing address:
  • Phone: 602-277-5551
  • Fax: 602-277-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04-33401
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number41627
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2002013720
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: