Provider Demographics
NPI:1508643628
Name:EAST VALLEY INFECTIOUS DISEASE MEDICINE LLC
Entity Type:Organization
Organization Name:EAST VALLEY INFECTIOUS DISEASE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHASHIKALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMENENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-241-0273
Mailing Address - Street 1:18637 E CARDINAL WAY STE 100A
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5546
Mailing Address - Country:US
Mailing Address - Phone:602-241-0273
Mailing Address - Fax:602-241-0249
Practice Address - Street 1:18637 E CARDINAL WAY STE 100A
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5546
Practice Address - Country:US
Practice Address - Phone:602-241-0273
Practice Address - Fax:602-241-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty