Provider Demographics
NPI:1033110317
Name:MUKHERJEE, SANJOYDEB (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJOYDEB
Middle Name:
Last Name:MUKHERJEE
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:PO BOX 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:859-572-3617
Mailing Address - Fax:859-572-2326
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-572-3617
Practice Address - Fax:859-572-2326
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36056207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200916700Medicaid
OH2594223Medicaid
KY64057839Medicaid
OH2594223Medicaid
KY64057839Medicaid
KY3400180Medicare PIN
KY3313255Medicare PIN
IN200916700Medicaid
P00247463Medicare PIN