Provider Demographics
NPI:1447201173
Name:MUTTREJA, SANJAY PRAKASH (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:PRAKASH
Last Name:MUTTREJA
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-6399
Practice Address - Fax:707-967-5915
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC132005207R00000X, 208M00000X
FLME73769207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263823100Medicaid
FLG63783Medicare UPIN
CACA216876Medicare PIN
FL42356VMedicare PIN
42356WMedicare PIN
FL263823100Medicaid
FL42356SMedicare PIN