Basic Information
| Provider Information | |||||||||
| NPI: | 1548287378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | SANJEEV | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 STONE RIDGE WAY | ||||||||
| Address2: | APT # 1E | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068245385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033664000 | ||||||||
| FaxNumber: | 2033822954 | ||||||||
| Practice Location | |||||||||
| Address1: | 968 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066051116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | 2033829425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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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 | 207R00000X | 039893 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 039893 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 039893 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004236130 | 05 | CT | MEDICAID |