Provider Demographics
NPI:1538178264
Name:GHOSH, SANJAY (PHD MD)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:GHOSH
Suffix:
Gender:M
Credentials:PHD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 CAROLINE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4902
Mailing Address - Country:US
Mailing Address - Phone:636-390-2288
Mailing Address - Fax:636-390-2277
Practice Address - Street 1:1080 CAROLINE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4902
Practice Address - Country:US
Practice Address - Phone:636-390-2288
Practice Address - Fax:636-390-2277
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6N94174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF07318Medicare UPIN