Provider Demographics
NPI:1851646665
Name:JASDANWALA, SARFARAZ ABDEALI (MD)
Entity Type:Individual
Prefix:DR
First Name:SARFARAZ
Middle Name:ABDEALI
Last Name:JASDANWALA
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 1:1003 HAUCK DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2584
Mailing Address - Country:US
Mailing Address - Phone:573-466-2056
Mailing Address - Fax:
Practice Address - Street 1:1003 HAUCK DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2584
Practice Address - Country:US
Practice Address - Phone:573-247-1487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021629207R00000X, 207RA0401X
IL036.162657207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.162657OtherSTATE LICENSE
IL336.120566OtherLICENSED PHYSICIAN CONTROLLED SUBSTANCE
IL036.162657OtherLICENSED PHYSICIAN CONTROLLED SUBSTANCE
CAC190524OtherSTATE LICENSE
MO2015021629OtherSTATE LICENSE
MO2500025774OtherCDS