Provider Demographics
NPI:1760429641
Name:VALLEY ALLERGY AND ASTHMA CLINIC PLLC
Entity Type:Organization
Organization Name:VALLEY ALLERGY AND ASTHMA CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOTHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-548-0981
Mailing Address - Street 1:PO BOX 5148
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85312-5148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5757 W THUNDERBIRD RD
Practice Address - Street 2:W205
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4641
Practice Address - Country:US
Practice Address - Phone:602-548-0981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
76402Medicare PIN