Provider Demographics
NPI:1881203156
Name:SANJUAN SANJUAN, ALBA (MD)
Entity type:Individual
Prefix:
First Name:ALBA
Middle Name:
Last Name:SANJUAN SANJUAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST STE 309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1853
Mailing Address - Country:US
Mailing Address - Phone:304-388-3290
Mailing Address - Fax:304-388-3186
Practice Address - Street 1:415 MORRIS ST STE 309
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-3290
Practice Address - Fax:304-388-3186
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4352000978204E00000X
FL390200000X
WV31823204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program