Healthcare Provider Details

I. General information

NPI: 1043091978
Provider Name (Legal Business Name): DESERT STREAM UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 E MULBERRY ST
SCOTTSDALE AZ
85251-5871
US

IV. Provider business mailing address

8118 E MULBERRY ST
SCOTTSDALE AZ
85251-5871
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-1121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KHALED FAREED
Title or Position: CEO
Credential: MD
Phone: 216-375-5223