Provider Demographics
NPI:1194906925
Name:SHAFA MEDICAL CLINIC PC
Entity type:Organization
Organization Name:SHAFA MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR /PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODESTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-248-8258
Mailing Address - Street 1:202 E EARLL DR STE 150
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2636
Mailing Address - Country:US
Mailing Address - Phone:602-248-8258
Mailing Address - Fax:602-248-8259
Practice Address - Street 1:202 E EARLL DR STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2636
Practice Address - Country:US
Practice Address - Phone:602-248-8258
Practice Address - Fax:602-248-8259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07569335N261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ447921Medicaid
AZAZ0860140OtherBC/BS
AZZ64150Medicare PIN