Provider Demographics
NPI:1346285566
Name:GHOSH, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:GHOSH
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 1:6645 ALVARADO RD
Mailing Address - Street 2:SUITE# 4000
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5208
Mailing Address - Country:US
Mailing Address - Phone:619-229-3105
Mailing Address - Fax:619-229-3127
Practice Address - Street 1:6645 ALVARADO RD
Practice Address - Street 2:SUITE# 4000
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-229-3105
Practice Address - Fax:619-229-3127
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62563207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A625630Medicaid
CAWA62563AMedicare ID - Type Unspecified
CAH68535Medicare UPIN