Provider Demographics
NPI:1477634632
Name:KUDTARKAR, SANJAY
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:KUDTARKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 N ARROWHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4116
Mailing Address - Country:US
Mailing Address - Phone:909-882-0988
Mailing Address - Fax:909-886-1301
Practice Address - Street 1:1998 N ARROWHEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4116
Practice Address - Country:US
Practice Address - Phone:909-882-0988
Practice Address - Fax:909-886-1301
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A649570Medicaid
CA00A649570Medicaid
CA00A649570Medicare PIN
CAG67632Medicare UPIN