Provider Demographics
NPI:1508851718
Name:YATHIRAJ, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:YATHIRAJ
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 14675
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-4675
Mailing Address - Country:US
Mailing Address - Phone:941-877-7007
Mailing Address - Fax:941-238-9119
Practice Address - Street 1:2902 59TH ST W STE D
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7021
Practice Address - Country:US
Practice Address - Phone:941-877-7007
Practice Address - Fax:941-238-9119
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME721702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43579OtherBCBS
FL130018343OtherRAILROAD MEDICARE
FL254228500Medicaid
E0470WMedicare PIN
FLG66620Medicare UPIN
FL254228500Medicaid
FLE0470ZMedicare PIN