Provider Demographics
NPI:1275686891
Name:SHRESTHA, SUJIT PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJIT
Middle Name:PRASAD
Last Name:SHRESTHA
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 1:75 COLONIA DE SALUD
Mailing Address - Street 2:STE 200D
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2487
Mailing Address - Country:US
Mailing Address - Phone:520-459-1984
Mailing Address - Fax:520-452-1011
Practice Address - Street 1:75 COLONIA DE SALUD
Practice Address - Street 2:STE 200D
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2487
Practice Address - Country:US
Practice Address - Phone:520-459-1984
Practice Address - Fax:520-452-1011
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33286174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI29360Medicare UPIN
AZ103164Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER