Provider Demographics
NPI:1558806570
Name:SANJAY KANDOTH MD PC
Entity Type:Organization
Organization Name:SANJAY KANDOTH MD PC
Other - Org Name:SUNRISE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KANDOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-254-5437
Mailing Address - Street 1:3061 S MARYLAND PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2298
Mailing Address - Country:US
Mailing Address - Phone:702-254-5437
Mailing Address - Fax:702-254-7354
Practice Address - Street 1:7200 SMOKE RANCH RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1115
Practice Address - Country:US
Practice Address - Phone:702-820-5437
Practice Address - Fax:702-254-7354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV33358Medicare PIN
NVH13866Medicare UPIN