Basic Information
Provider Information | |||||||||
NPI: | 1376513085 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VOHRA | ||||||||
FirstName: | SANJEEV | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 202 TAUGHANNOCK BLVD | ||||||||
Address2: | PO BOX 366 | ||||||||
City: | ITHACA | ||||||||
State: | NY | ||||||||
PostalCode: | 148503328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072774035 | ||||||||
FaxNumber: | 6072773888 | ||||||||
Practice Location | |||||||||
Address1: | 1301 TRUMANSBURG RD | ||||||||
Address2: | SUITE M | ||||||||
City: | ITHACA | ||||||||
State: | NY | ||||||||
PostalCode: | 148501397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072738502 | ||||||||
FaxNumber: | 6072736115 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2006 | ||||||||
LastUpdateDate: | 11/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 191391 | NY | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 01682920 | 05 | NY |   | MEDICAID |