Provider Demographics
NPI:1629234521
Name:JACOB, SANJIVINI VISHWAS (M D)
Entity Type:Individual
Prefix:DR
First Name:SANJIVINI
Middle Name:VISHWAS
Last Name:JACOB
Suffix:
Gender:F
Credentials:M D
Other - Prefix:DR
Other - First Name:SANJIVINI
Other - Middle Name:VISHWAS
Other - Last Name:DHANAWADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:6141 SHALLOWFORD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1663
Mailing Address - Country:US
Mailing Address - Phone:423-498-2000
Mailing Address - Fax:423-498-2001
Practice Address - Street 1:6141 SHALLOWFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1663
Practice Address - Country:US
Practice Address - Phone:423-498-2000
Practice Address - Fax:423-498-2001
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0448482083A0300X, 2083A0300X
FLME 102241207ZP0101X
TN448482083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047258Medicaid