Provider Demographics
NPI:1972549632
Name:MATHUR, SANDIP VIJAYSHANKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDIP
Middle Name:VIJAYSHANKAR
Last Name:MATHUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5496
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5496
Mailing Address - Country:US
Mailing Address - Phone:325-692-3777
Mailing Address - Fax:325-695-2659
Practice Address - Street 1:6300 REGIONAL PLZ
Practice Address - Street 2:SUITE 820
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5251
Practice Address - Country:US
Practice Address - Phone:325-692-3777
Practice Address - Fax:325-695-2659
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7076174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110648604Medicaid
TX118749104OtherFIRSTCARE
TN8AJ206OtherBCBS
TXA002OtherTRICARE
TX118749104OtherFIRSTCARE
TXA002OtherTRICARE