Provider Demographics
NPI:1326258583
Name:TENDOLKAR, SANJEEV S (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:S
Last Name:TENDOLKAR
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 1:4589 LAWRENCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7320
Mailing Address - Country:US
Mailing Address - Phone:770-466-8672
Mailing Address - Fax:770-466-2082
Practice Address - Street 1:4589 LAWRENCEVILLE RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7320
Practice Address - Country:US
Practice Address - Phone:770-466-8672
Practice Address - Fax:770-466-2082
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I084637OtherMEDICARE PTAN
GA202I084637Medicare PIN