Provider Demographics
NPI:1093813990
Name:WASAN, SANJEEV MADANLAL (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:MADANLAL
Last Name:WASAN
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 1:19420 GOLF VISTA PLZ
Mailing Address - Street 2:STE 230
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8267
Mailing Address - Country:US
Mailing Address - Phone:703-724-4480
Mailing Address - Fax:703-724-7743
Practice Address - Street 1:19420 GOLF VISTA PLZ STE 230
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8267
Practice Address - Country:US
Practice Address - Phone:703-724-4480
Practice Address - Fax:703-724-7743
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237806207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I38390Medicare UPIN