Healthcare Provider Details

I. General information

NPI: 1417202201
Provider Name (Legal Business Name): SRIHARSHA VAJJALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 E HARTFORD DR STE 100
SCOTTSDALE AZ
85255
US

IV. Provider business mailing address

8330 E HARTFORD DR STE 100
SCOTTSDALE AZ
85255-7205
US

V. Phone/Fax

Practice location:
  • Phone: 480-745-3547
  • Fax: 480-745-3548
Mailing address:
  • Phone: 480-745-3547
  • Fax: 480-745-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52075
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number52075
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: