Provider Demographics
NPI:1922408756
Name:UTAMA, SANJAYA SATRIYA
Entity Type:Individual
Prefix:MR
First Name:SANJAYA
Middle Name:SATRIYA
Last Name:UTAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 SIERRA CT # B # A - 115
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7607
Mailing Address - Country:US
Mailing Address - Phone:661-886-0287
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT UNIT B # A -115
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550
Practice Address - Country:US
Practice Address - Phone:661-886-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver