Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 45843 | AZ |
Y | 2080P0204X | Pediatric Emergency Doctor | 45843 | AZ |
NPI | 1245564772 |
---|---|
Provider Name | Dr. Vasanth Kiran Coorg |
First Address | Phoenix, AZ 85018-2327 |
Second Address | Phoenix, AZ 85016-7710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2009 |
Last Update Date | 31/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
733769 | (05) | AZ |