Provider Demographics
NPI:1790892016
Name:SUBBU, MAHESH R (MD)
Entity Type:Individual
Prefix:
First Name:MAHESH
Middle Name:R
Last Name:SUBBU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAHESH
Other - Middle Name:
Other - Last Name:RAMA SUBBU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2851 S AVENUE B STE 1201
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7745
Mailing Address - Country:US
Mailing Address - Phone:928-329-7000
Mailing Address - Fax:928-329-9303
Practice Address - Street 1:2851 S AVENUE B STE 1201
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7745
Practice Address - Country:US
Practice Address - Phone:928-329-7000
Practice Address - Fax:928-329-9303
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33028207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ891855Medicaid
AZZ100675Medicare ID - Type Unspecified
AZ891855Medicaid