Provider Demographics
NPI:1699744169
Name:KHACHATURIAN, THADDEUS (MD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:KHACHATURIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 E GREENWAY PKWY # 103-447
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2065
Mailing Address - Country:US
Mailing Address - Phone:480-922-4923
Mailing Address - Fax:480-922-4924
Practice Address - Street 1:15612 N 32ND ST
Practice Address - Street 2:STE. #3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3859
Practice Address - Country:US
Practice Address - Phone:602-251-8052
Practice Address - Fax:602-251-8068
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13453207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99754Medicare UPIN
AZZ70939Medicare ID - Type UnspecifiedINDIV MC # TAACH GRP
AZZ22WCGXK04Medicare ID - Type UnspecifiedINDIV MC# FOR CANYON