Provider Demographics
NPI:1023237864
Name:THARA DAMODARAN MD LLC
Entity type:Organization
Organization Name:THARA DAMODARAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THARA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAMODARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-720-8744
Mailing Address - Street 1:PO BOX 20490
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-0490
Mailing Address - Country:US
Mailing Address - Phone:480-985-1093
Mailing Address - Fax:480-296-7665
Practice Address - Street 1:1925 NW 142ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6193
Practice Address - Country:US
Practice Address - Phone:405-706-3117
Practice Address - Fax:877-349-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35774207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL13560915OtherORGANIZATION REGISTRATION
AZI62308Medicare UPIN