Provider Demographics
NPI:1679594055
Name:GARG, SANJAY K (MBBS)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:K
Last Name:GARG
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:
Practice Address - Street 1:116 W BUCHANAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2522
Practice Address - Country:US
Practice Address - Phone:217-345-7700
Practice Address - Fax:217-345-7200
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058382A208000000X
IL036095041208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200465180Medicaid
INH24302Medicare UPIN