Provider Demographics
NPI:1255622577
Name:SANJAY KANDOTH MD PC
Entity type:Organization
Organization Name:SANJAY KANDOTH MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KANDOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-254-5437
Mailing Address - Street 1:PO BOX 60515
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89160
Mailing Address - Country:US
Mailing Address - Phone:702-254-5437
Mailing Address - Fax:702-254-7354
Practice Address - Street 1:7875 S RAINBOW BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-6469
Practice Address - Country:US
Practice Address - Phone:702-254-5437
Practice Address - Fax:702-254-7354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANJAY KANDOTH MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV33358Medicare PIN
NVH13866Medicare UPIN