Provider Demographics
NPI:1114199148
Name:MAHADEVAN, ARVIND (MD)
Entity Type:Individual
Prefix:
First Name:ARVIND
Middle Name:
Last Name:MAHADEVAN
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 1:20340 N LAKE PLEASANT RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9714
Mailing Address - Country:US
Mailing Address - Phone:623-299-9988
Mailing Address - Fax:623-328-7804
Practice Address - Street 1:20340 N LAKE PLEASANT RD
Practice Address - Street 2:SUITE 109
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9714
Practice Address - Country:US
Practice Address - Phone:623-299-9988
Practice Address - Fax:623-328-7804
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ125634Medicare PIN