Healthcare Provider Details

I. General information

NPI: 1912153222
Provider Name (Legal Business Name): SANDEEP MALLANAGOUDA PATIL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S STAPLEY DR STE 120
MESA AZ
85204-6676
US

IV. Provider business mailing address

2040 S ALMA SCHOOL RD STE 1
CHANDLER AZ
85286-7076
US

V. Phone/Fax

Practice location:
  • Phone: 602-525-5674
  • Fax:
Mailing address:
  • Phone: 480-290-1822
  • Fax: 949-864-3908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number202074
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number50371
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: