Provider Demographics
NPI:1609361971
Name:MUDIYAM, CHETHAN RAM (MD)
Entity Type:Individual
Prefix:
First Name:CHETHAN
Middle Name:RAM
Last Name:MUDIYAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:602-839-3827
Mailing Address - Fax:602-839-2359
Practice Address - Street 1:1441 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-521-5700
Practice Address - Fax:602-521-5701
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZR77674207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology