Healthcare Provider Details

I. General information

NPI: 1265497242
Provider Name (Legal Business Name): SANJAY REUBEN DASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16221 SAINT VINCENT WAY
LITTLE ROCK AR
72223-9072
US

IV. Provider business mailing address

16221 SAINT VINCENT WAY
LITTLE ROCK AR
72223-9072
US

V. Phone/Fax

Practice location:
  • Phone: 501-552-8150
  • Fax: 501-552-8199
Mailing address:
  • Phone: 501-552-8150
  • Fax: 501-552-8199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberE-4008
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE4008
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: