Provider Demographics
NPI:1487673760
Name:MAITRA, SUBHASIS KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBHASIS
Middle Name:KUMAR
Last Name:MAITRA
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 1:3400 N DYSART RD
Mailing Address - Street 2:UNIT G-127
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-1011
Mailing Address - Country:US
Mailing Address - Phone:623-882-0077
Mailing Address - Fax:623-882-9977
Practice Address - Street 1:3400 N DYSART RD
Practice Address - Street 2:UNIT G-127
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-1011
Practice Address - Country:US
Practice Address - Phone:623-882-0077
Practice Address - Fax:623-882-9977
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31810207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDE3350OtherRAILROAD MEDICARE
AZ833344OtherAHCCCS
AZZ77754Medicare PIN
AZI00543Medicare UPIN
AZZ77756Medicare PIN