Provider Demographics
NPI:1962459826
Name:MATHUR, SANJEEV (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:
Last Name:MATHUR
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 1:3235 N WELLNESS DR
Mailing Address - Street 2:SUITE 120B BLDG A
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3235 N WELLNESS DR
Practice Address - Street 2:#120B
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7264
Practice Address - Country:US
Practice Address - Phone:616-399-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0D16150036Medicare ID - Type Unspecified
F65330Medicare UPIN