Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086X0206X | Surgical Oncologist | 4264 | AZ |
NPI | 1124019575 |
---|---|
Provider Name | Sivakami Brenda Moorthy |
First Address | Glendale, AZ 85306-4641 |
Second Address | Glendale, AZ 85306-4641 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 21/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
954900 | (05) | AZ |
I15778 | (02) | AZ |