Provider Demographics
NPI:1124019575
Name:MOORTHY, SIVAKAMI BRENDA (DO)
Entity Type:Individual
Prefix:
First Name:SIVAKAMI
Middle Name:BRENDA
Last Name:MOORTHY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:S
Other - Middle Name:BRENDA
Other - Last Name:MOORTHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:5757 W THUNDERBIRD RD
Mailing Address - Street 2:E351
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4641
Mailing Address - Country:US
Mailing Address - Phone:602-374-3440
Mailing Address - Fax:602-374-3441
Practice Address - Street 1:5757 W THUNDERBIRD RD
Practice Address - Street 2:E351
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4641
Practice Address - Country:US
Practice Address - Phone:602-374-3440
Practice Address - Fax:602-374-3441
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42642086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ954900Medicaid
AZ105046Medicare ID - Type Unspecified
AZI15778Medicare UPIN