Healthcare Provider Details

I. General information

NPI: 1720354988
Provider Name (Legal Business Name): SARA ROYA SHADARAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2012
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 95460
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax: 602-263-1619
Mailing address:
  • Phone: 602-581-6076
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.127900
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number57878
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.127900
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number57878
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: