Provider Demographics
NPI:1518136241
Name:FLAGSTAFF NEUROLOGY
Entity Type:Organization
Organization Name:FLAGSTAFF NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICCIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-403-1701
Mailing Address - Street 1:618 N HUMPHREYS ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3024
Mailing Address - Country:US
Mailing Address - Phone:928-774-2459
Mailing Address - Fax:
Practice Address - Street 1:4275 EXECUTIVE SQ STE 200
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1476
Practice Address - Country:US
Practice Address - Phone:619-403-1701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ100913Medicare PIN