Basic Information
| Provider Information | |||||||||
| NPI: | 1174615017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHAR | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CHASE PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037556677 | ||||||||
| FaxNumber: | 2037557166 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CHASE PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037556677 | ||||||||
| FaxNumber: | 2037557166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 049078 | CT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PS0010X | 049078 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 208VP0000X | 049078 | CT | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001421800 | 05 | FL | MEDICAID | 02838200 | 05 | NY | MEDICAID |