Basic Information
| Provider Information | |||||||||
| NPI: | 1578721221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASILAMANI | ||||||||
| FirstName: | SANJAY | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE BLDG 91 | ||||||||
| Address2: | ATTN TOBIE SHELLEY | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 97 GREAT TEAYS BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3042015019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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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 | 2084P0800X | 390200000X | WV | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 078825 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3810021770 | 05 | WV | MEDICAID | 0083183 | 05 | OH | MEDICAID | 7100223220 | 05 | KY | MEDICAID |