Provider Demographics
NPI:1982882882
Name:TIYYAGURA, SANDEEP (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:
Last Name:TIYYAGURA
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 1:140 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2505
Mailing Address - Country:US
Mailing Address - Phone:203-597-9733
Mailing Address - Fax:203-597-9732
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2505
Practice Address - Country:US
Practice Address - Phone:203-597-9733
Practice Address - Fax:203-597-9732
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT048549207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program