Provider Demographics
NPI:1992812242
Name:SUBBU, SONAL M (MD)
Entity type:Individual
Prefix:
First Name:SONAL
Middle Name:M
Last Name:SUBBU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SONAL
Other - Middle Name:M
Other - Last Name:SUBBU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2150 W 24TH STREET
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-819-7000
Mailing Address - Fax:928-329-9303
Practice Address - Street 1:2150 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6122
Practice Address - Country:US
Practice Address - Phone:928-819-7000
Practice Address - Fax:928-329-9303
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33107208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81968Medicaid
AZZ101520Medicare ID - Type Unspecified
AZ81968Medicaid