Basic Information
| Provider Information | |||||||||
| NPI: | 1780784710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DARIRA | ||||||||
| FirstName: | SYAMALA | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DARIRA | ||||||||
| OtherFirstName: | SYMALA | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 11720 | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287715487 | ||||||||
| FaxNumber: | 9087715471 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 WILLOW CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287715487 | ||||||||
| FaxNumber: | 9287715471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 37414 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | AZ40118 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 93322534 | 05 | CO | MEDICAID | 332525 | 05 | AZ | MEDICAID |