Provider Demographics
NPI:1447434592
Name:EAST MESA PEDIATRICS, INC
Entity type:Organization
Organization Name:EAST MESA PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KOJASTEH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GHAZIASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-396-2087
Mailing Address - Street 1:6142 E BROWN RD
Mailing Address - Street 2:#102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4962
Mailing Address - Country:US
Mailing Address - Phone:480-396-2087
Mailing Address - Fax:480-396-3973
Practice Address - Street 1:6142 E BROWN RD
Practice Address - Street 2:#102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4962
Practice Address - Country:US
Practice Address - Phone:480-396-2087
Practice Address - Fax:480-396-3973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343092080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ964149Medicaid
AZC99539Medicare UPIN