Provider Demographics
NPI:1407175284
Name:SHAHLA, SAMMYA (MD)
Entity Type:Individual
Prefix:
First Name:SAMMYA
Middle Name:
Last Name:SHAHLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11209 N TATUM BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6060
Mailing Address - Country:US
Mailing Address - Phone:602-494-5155
Mailing Address - Fax:602-494-5115
Practice Address - Street 1:11209 N TATUM BLVD STE 180
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6060
Practice Address - Country:US
Practice Address - Phone:602-494-5155
Practice Address - Fax:602-494-5115
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine