Provider Demographics
NPI:1659786911
Name:GEORGE, SANJU (MD)
Entity Type:Individual
Prefix:
First Name:SANJU
Middle Name:
Last Name:GEORGE
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 1:9730 WYNMILL RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1804
Mailing Address - Country:US
Mailing Address - Phone:267-978-1582
Mailing Address - Fax:
Practice Address - Street 1:9730 WYNMILL RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1804
Practice Address - Country:US
Practice Address - Phone:267-978-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2125572084P0804X
PAMD4625052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry