Healthcare Provider Details

I. General information

NPI: 1104237478
Provider Name (Legal Business Name): MASOUD SULTANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N 19TH AVE STE 103
PHOENIX AZ
85015-2451
US

IV. Provider business mailing address

1019 E IRMA LN
PHOENIX AZ
85024-4114
US

V. Phone/Fax

Practice location:
  • Phone: 602-589-0500
  • Fax: 602-314-4552
Mailing address:
  • Phone: 602-463-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number56887
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number56887
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: