Provider Demographics
NPI:1558350702
Name:GOYAL, SANJIVA (MD)
Entity Type:Individual
Prefix:
First Name:SANJIVA
Middle Name:
Last Name:GOYAL
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 2878
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-2878
Mailing Address - Country:US
Mailing Address - Phone:904-567-1050
Mailing Address - Fax:
Practice Address - Street 1:2804 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:STE 109
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3776
Practice Address - Country:US
Practice Address - Phone:904-727-9123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80506207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG49010Medicare UPIN
FL35493Medicare ID - Type Unspecified