Provider Demographics
NPI:1235549601
Name:WONTAKAL, SANDEEP NAGARAJ (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:NAGARAJ
Last Name:WONTAKAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 168TH ST # 1401
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3723
Mailing Address - Country:US
Mailing Address - Phone:212-305-8533
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291355207ZP0105X, 207ZP0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine