MEDICARE: XPRESS NEURODIAGNOSTIC LLC

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	2084E0001X	Epilepsy Physician
2	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1578381158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XPRESS NEURODIAGNOSTIC LLC

Provider Business Mailing Address
First Line	:	12409 W INDIAN SCHOOL RD STE A108
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85392-9503
Country	:	US
Telephone Number	:	623-238-3889
Fax Number	:

Provider Business Practice Location Address
First Line	:	3719 E LOUISE DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-8314
Country	:	US
Telephone Number	:	623-328-7087
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	AZIZ MALLIK
Credential	:
Telephone Number	:	623-238-3889

Provider Enumeration Date	:	10/01/2024
Last Update Date	:	11/13/2025

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