MEDICARE: SAMMYA SHAHLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	53949	AZ

General Provider Information

NPI Number	:	1407175284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMMYA SHAHLA MD

Provider Business Mailing Address
First Line	:	11209 N TATUM BLVD STE 180
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6060
Country	:	US
Telephone Number	:	602-494-5155
Fax Number	:	602-494-5115

Provider Business Practice Location Address
First Line	:	11209 N TATUM BLVD STE 180
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6060
Country	:	US
Telephone Number	:	602-494-5155
Fax Number	:	602-494-5115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	11/19/2020

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