Provider Demographics
NPI:1568531424
Name:SASTRY, SANJAY SURY (M D)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:SURY
Last Name:SASTRY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1860
Mailing Address - Country:US
Mailing Address - Phone:407-473-5525
Mailing Address - Fax:386-756-1697
Practice Address - Street 1:801 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1860
Practice Address - Country:US
Practice Address - Phone:386-788-2300
Practice Address - Fax:386-756-1697
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME848202084A0401X
FLME 84820208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG22877Medicare UPIN
AZG22877Medicare UPIN