Basic Information
| Provider Information | |||||||||
| NPI: | 1639151749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLASA | ||||||||
| FirstName: | NAVAZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 38 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
| FaxNumber: | 6025281225 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 W SEED FARM RD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
| FaxNumber: | 6025281225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 02/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33070 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 908155 | 05 | AZ | MEDICAID |