Provider Demographics
NPI:1407826514
Name:SANANMAN, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:SANANMAN
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 1:700 BROAD ST
Mailing Address - Street 2:STE 201
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208
Mailing Address - Country:US
Mailing Address - Phone:908-354-3994
Mailing Address - Fax:908-354-0429
Practice Address - Street 1:700 BROAD ST
Practice Address - Street 2:STE 201
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208
Practice Address - Country:US
Practice Address - Phone:908-354-3994
Practice Address - Fax:908-354-0429
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2021-03-10
Deactivation Date:2020-09-01
Deactivation Code:
Reactivation Date:2021-03-10
Provider Licenses
StateLicense IDTaxonomies
NJ25MA025227002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0553808Medicaid
533648A3TMedicare ID - Type Unspecified
C58982Medicare UPIN