Healthcare Provider Details

I. General information

NPI: 1457559486
Provider Name (Legal Business Name): CHILDREN'S DOCTOR, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 W GLENDALE AVE SUITE #102
PHOENIX AZ
85021-8860
US

IV. Provider business mailing address

1728 W GLENDALE AVE SUITE #102
PHOENIX AZ
85021-8860
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 Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. KERAMAT BEHSHAD
Title or Position: PRESIDENT
Credential: 20101
Phone: 602-864-0211