Basic Information
| Provider Information | |||||||||
| NPI: | 1386691988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIGAM | ||||||||
| FirstName: | RENUKA | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850168034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 59 S HIBBERT | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852101414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803446226 | ||||||||
| FaxNumber: | 4803446201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 28287 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 547565 | 05 | AZ | MEDICAID |