Provider Demographics
NPI:1508643628
Name:EAST VALLEY INFECTIOUS DISEASE MEDICINE LLC
Entity type:Organization
Organization Name:EAST VALLEY INFECTIOUS DISEASE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:SHASHIKALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMENENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-648-7895
Mailing Address - Street 1:EVIDM LOCKBOX DEPT 880778
Mailing Address - Street 2:PO BOX 29650
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:480-648-7895
Mailing Address - Fax:623-552-3320
Practice Address - Street 1:6040 E MAIN ST # 516
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8928
Practice Address - Country:US
Practice Address - Phone:480-648-7895
Practice Address - Fax:623-552-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty