Healthcare Provider Details

I. General information

NPI: 1861945818
Provider Name (Legal Business Name): SRI RAGHAV SISTA M.D.,M.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-8935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number67346
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number69526
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberT5036
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberT5036
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: