Healthcare Provider Details

I. General information

NPI: 1346509742
Provider Name (Legal Business Name): YAZHINI SRIVATHSAL M.B.B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YAZHINI GNANASAMBANTHAN

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 S PERSHING AVE
SALEM MO
65560-1845
US

IV. Provider business mailing address

7575 E EARLL DR
SCOTTSDALE AZ
85251-6915
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 480-448-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2019012547
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52855
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: