Provider Demographics
NPI:1912402660
Name:JATTA, EBRAHIM (NMD)
Entity Type:Individual
Prefix:DR
First Name:EBRAHIM
Middle Name:
Last Name:JATTA
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8962 E DESERT COVE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6984
Mailing Address - Country:US
Mailing Address - Phone:480-248-6807
Mailing Address - Fax:480-248-6737
Practice Address - Street 1:8962 E DESERT COVE AVE STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6984
Practice Address - Country:US
Practice Address - Phone:480-248-6807
Practice Address - Fax:480-248-6737
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1699175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ18-1699OtherNATUROPATHIC MEDICAL DOCTOR