Provider Demographics
NPI:1457580995
Name:SANGROULA, DAISY
Entity Type:Individual
Prefix:DR
First Name:DAISY
Middle Name:
Last Name:SANGROULA
Suffix:
Gender:F
Credentials:
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0330
Mailing Address - Fax:
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-852-5851
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092207207L00000X
KY43890207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK077070OtherMEDICARE
KY43890OtherLICENSE
KY7100236170Medicaid
IN201177140Medicaid