Basic Information
| Provider Information | |||||||||
| NPI: | 1912153222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATIL | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | MALLANAGOUDA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD | ||||||||
| Address2: | 102 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S POWER RD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852065241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808349039 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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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 | 202074 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 50371 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 030611 | 05 | AZ | MEDICAID | 1893846 | 05 | LA | MEDICAID |