Provider Demographics
NPI:1770553265
Name:TALATI, SANJAY J (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:J
Last Name:TALATI
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 1:3264 N EVERGREEN DRIVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DRIVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010606202085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4088895Medicaid
MI0N49230017Medicare PIN
G48690Medicare UPIN
MI0G36004018Medicare PIN