Provider Demographics
NPI:1578721221
Name:MASILAMANI, SANJAY STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:STANLEY
Last Name:MASILAMANI
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 1:3495 PIEDMONT RD NE BLDG 91
Mailing Address - Street 2:ATTN TOBIE SHELLEY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:97 GREAT TEAYS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9816
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-201-5019
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV390200000X2084P0800X
GA0788252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021770Medicaid
OH0083183Medicaid
KY7100223220Medicaid
WV2033031Medicare PIN
KY7100223220Medicaid
WV3810021770Medicaid
WVWV1018BMedicare PIN