Basic Information
| Provider Information | |||||||||
| NPI: | 1164935482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANJAY OM TEWARI MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117620270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642030 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Practice Location | |||||||||
| Address1: | 3632 NOSTRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112295305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183324409 | ||||||||
| FaxNumber: | 7183324472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | TEWARI | ||||||||
| AuthorizedOfficialFirstName: | SANJAY | ||||||||
| AuthorizedOfficialMiddleName: | OM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6464684563 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.