Provider Demographics
NPI:1760645667
Name:VANNARATH, PRIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:
Last Name:VANNARATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 N 3RD ST
Mailing Address - Street 2:SUITE 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1130
Mailing Address - Country:US
Mailing Address - Phone:602-323-3345
Mailing Address - Fax:602-323-3399
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX533339208000000X
AZPENDING208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics