Provider Demographics
NPI:1881637296
Name:HAVALDAR, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:HAVALDAR
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 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:3901 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6538
Practice Address - Country:US
Practice Address - Phone:417-875-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116190207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203834106Medicaid
114559OtherBLUE CROSS/BLUE SHIELD
114559OtherBLUE CROSS/BLUE SHIELD
MO203834106Medicaid