Provider Demographics
NPI:1003821430
Name:GOPAL, SANJEEV (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:
Last Name:GOPAL
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 1:6424 E BROADWAY RD
Mailing Address - Street 2:104-105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1750
Mailing Address - Country:US
Mailing Address - Phone:602-802-8700
Mailing Address - Fax:602-802-8799
Practice Address - Street 1:6424 E BROADWAY RD
Practice Address - Street 2:104-105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1750
Practice Address - Country:US
Practice Address - Phone:602-802-8700
Practice Address - Fax:602-802-8799
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276077207RH0003X
AZ35361207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1710322946OtherZ159340
AZ1003821430OtherBLUE CROSS BLUE SHIELD
AZ178311Medicaid
AZ7905050OtherAETNA
AZ5336171OtherCIGNA
AZP00853763OtherRAILROAD MEDICARE
AZ206531OtherUNIVERSAL
AZ3Z4309OtherHEALTH NET
AZP00853763OtherRAILROAD MEDICARE
AZZ138210Medicare PIN