Provider Demographics
NPI:1548641871
Name:IDDYADINESH, SANJANA (DO)
Entity type:Individual
Prefix:DR
First Name:SANJANA
Middle Name:
Last Name:IDDYADINESH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 S HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6138
Mailing Address - Country:US
Mailing Address - Phone:864-987-9990
Mailing Address - Fax:
Practice Address - Street 1:3904 S HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6138
Practice Address - Country:US
Practice Address - Phone:864-987-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-02717207Q00000X
SC83144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1548641871Medicaid