Provider Demographics
NPI:1083728323
Name:SANGWAN, ANIL (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:
Last Name:SANGWAN
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 1:116 TERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1329
Mailing Address - Country:US
Mailing Address - Phone:631-928-2002
Mailing Address - Fax:631-473-4427
Practice Address - Street 1:116 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1329
Practice Address - Country:US
Practice Address - Phone:631-928-2002
Practice Address - Fax:631-473-4427
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG91851Medicare UPIN
NY49C171Medicare PIN