Provider Demographics
NPI:1881756179
Name:HEGDE, SANJAY R (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:R
Last Name:HEGDE
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 1:955 MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4302
Mailing Address - Country:US
Mailing Address - Phone:781-729-5855
Mailing Address - Fax:781-721-5891
Practice Address - Street 1:955 MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1961
Practice Address - Country:US
Practice Address - Phone:781-729-5855
Practice Address - Fax:781-721-5891
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT183245207RG0100X
MDD69588207RG0100X
MA247933207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD418373800Medicaid
MDS062-0364OtherBLUE CROSS/BLUE SHIELD - REGIONAL
MD954004-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD418373800Medicaid
MD165452Y1PMedicare PIN