Provider Demographics
NPI:1821086190
Name:KANDOTH, SANJAY W (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:W
Last Name:KANDOTH
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:PO BOX 60515
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89160-0515
Mailing Address - Country:US
Mailing Address - Phone:702-254-5437
Mailing Address - Fax:702-254-7354
Practice Address - Street 1:3025 S MARYLAND PKWY
Practice Address - Street 2:SUITE #B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-6221
Practice Address - Country:US
Practice Address - Phone:702-254-5437
Practice Address - Fax:702-254-7354
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018417Medicaid
NV003102417Medicaid
NV002018417Medicaid
NV003102417Medicaid