Provider Demographics
NPI:1881649259
Name:DJAVADI, NASSER (MD)
Entity Type:Individual
Prefix:
First Name:NASSER
Middle Name:
Last Name:DJAVADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17215 N 72ND DR
Mailing Address - Street 2:BLDG D #140A
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8579
Mailing Address - Country:US
Mailing Address - Phone:623-487-9630
Mailing Address - Fax:623-487-9631
Practice Address - Street 1:17215 N 72ND DR
Practice Address - Street 2:BLDG D #140A
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8579
Practice Address - Country:US
Practice Address - Phone:623-487-9630
Practice Address - Fax:623-487-9631
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ232402084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
150581998Medicare ID - Type Unspecified
D36767Medicare UPIN