Provider Demographics
NPI:1790728574
Name:GARG, SANJEEV (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:
Last Name:GARG
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 1:517 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5756
Mailing Address - Country:US
Mailing Address - Phone:570-763-4690
Mailing Address - Fax:
Practice Address - Street 1:517 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5756
Practice Address - Country:US
Practice Address - Phone:570-763-4690
Practice Address - Fax:570-288-9613
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4200952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100999892Medicaid
078975Medicare ID - Type Unspecified
I06185Medicare UPIN