Basic Information
| Provider Information | |||||||||
| NPI: | 1346237385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARDOLKAR | ||||||||
| FirstName: | SANJAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4439 STATE ROUTE 159 STE G10 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794300 | ||||||||
| FaxNumber: | 7407794391 | ||||||||
| Practice Location | |||||||||
| Address1: | 4439 STATE ROUTE 159 STE G10 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794300 | ||||||||
| FaxNumber: | 7407794391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2015-01700 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 19900 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 35077587 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | 35.077587 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1346237385 | 05 | NC | MEDICAID | NC2514 | 05 | SC | MEDICAID | 2143040 | 05 | OH | MEDICAID | 6700083000 | 05 | WV | MEDICAID |