Provider Demographics
NPI:1740702984
Name:PRADHAN, SUPRIYA (MD)
Entity type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:PRADHAN
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 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3492
Mailing Address - Fax:
Practice Address - Street 1:1840 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1614
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:480-927-1092
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ62859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ095780Medicaid