Provider Demographics
NPI:1053309039
Name:SAYALOLIPAVAN, THIHALOLIPAVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THIHALOLIPAVAN
Middle Name:
Last Name:SAYALOLIPAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6948
Mailing Address - Country:US
Mailing Address - Phone:602-834-9071
Mailing Address - Fax:877-541-4239
Practice Address - Street 1:2070 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6948
Practice Address - Country:US
Practice Address - Phone:602-834-9071
Practice Address - Fax:877-541-4239
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204887207Q00000X
AZ65664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC6009Medicare ID - Type Unspecified
NYG17599Medicare UPIN