Provider Demographics
NPI:1073583803
Name:PATWARDHAN, SANJAY A (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:A
Last Name:PATWARDHAN
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 958946
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-8946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:314-576-0809
Practice Address - Street 1:14314 MANDERLEIGH WOODS DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-8055
Practice Address - Country:US
Practice Address - Phone:636-566-8155
Practice Address - Fax:314-576-0809
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107804207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073583803Medicaid
IL1073583803Medicaid
MO139000042Medicare PIN