Basic Information
| Provider Information | |||||||||
| NPI: | 1083701239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NARENDRA P MYNENI MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6970 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852166970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 S DOBSON RD | ||||||||
| Address2: | SUITE A302 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852024712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | MYNENI | ||||||||
| AuthorizedOfficialFirstName: | NARENDRA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4809851093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | AZ0032580 | 01 | AZ | BCBS | OTHER |