Provider Demographics
NPI:1578604690
Name:UDANI, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:UDANI
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 1:5737 KANAN RD
Mailing Address - Street 2:#454
Mailing Address - City:AGOURA
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1601
Mailing Address - Country:US
Mailing Address - Phone:818-318-9087
Mailing Address - Fax:
Practice Address - Street 1:5737 KANAN RD
Practice Address - Street 2:#454
Practice Address - City:AGOURA
Practice Address - State:CA
Practice Address - Zip Code:91301-1601
Practice Address - Country:US
Practice Address - Phone:818-318-9087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162676208M00000X
MI4301502046207R00000X
IL036141765207R00000X, 208M00000X
CAA54697207R00000X, 208M00000X
MO2019034404208M00000X
IN01084442A208M00000X
VA0101269836208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG49073Medicare UPIN