Provider Demographics
NPI:1144975269
Name:RASANANI, SAM MEHRDAD (OTD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:MEHRDAD
Last Name:RASANANI
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 E GATEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6154
Mailing Address - Country:US
Mailing Address - Phone:267-285-6534
Mailing Address - Fax:
Practice Address - Street 1:6635 W HAPPY VALLEY RD STE A104-218
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-2609
Practice Address - Country:US
Practice Address - Phone:623-224-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008668225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics