Provider Demographics
NPI:1427359165
Name:BRENDA MOORTHY DO PLLC
Entity Type:Organization
Organization Name:BRENDA MOORTHY DO PLLC
Other - Org Name:COMPREHENSIVE BREAST SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:BRENDA
Authorized Official - Last Name:MOORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-374-3440
Mailing Address - Street 1:5150 N 16TH ST
Mailing Address - Street 2:STE B232
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3990
Mailing Address - Country:US
Mailing Address - Phone:602-374-3440
Mailing Address - Fax:602-374-3441
Practice Address - Street 1:9179 W THUNDERBIRD RD
Practice Address - Street 2:STE 101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4912
Practice Address - Country:US
Practice Address - Phone:602-374-3440
Practice Address - Fax:602-374-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ573751Medicaid
AZ573751Medicaid