Provider Demographics
NPI:1912153222
Name:PATIL, SANDEEP MALLANAGOUDA (MD)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:MALLANAGOUDA
Last Name:PATIL
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 1:2149 E WARNER RD
Mailing Address - Street 2:102
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:480-610-6189
Practice Address - Street 1:301 S POWER RD
Practice Address - Street 2:STE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5241
Practice Address - Country:US
Practice Address - Phone:480-834-9039
Practice Address - Fax:480-610-6189
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202074207R00000X
AZ50371207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030611Medicaid
LA1893846Medicaid
LA4M225F600Medicare PIN
AZZ177702Medicare PIN
AZZ177704Medicare PIN