Basic Information
| Provider Information | |||||||||
| NPI: | 1417202201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAJJALA | ||||||||
| FirstName: | SRIHARSHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8330 E HARTFORD DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852557205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807453547 | ||||||||
| FaxNumber: | 4807453548 | ||||||||
| Practice Location | |||||||||
| Address1: | 8330 E HARTFORD DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807453547 | ||||||||
| FaxNumber: | 4807453548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 52075 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0012X | 52075 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 149601 | 05 | AZ | MEDICAID |