Healthcare Provider Details

I. General information

NPI: 1508030461
Provider Name (Legal Business Name): RANVIR SANDHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 SAND CREEK RD
ANTIOCH CA
94531-8687
US

IV. Provider business mailing address

801 OSTRUM ST ENROLLMENT CENTER
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 570-992-4208
  • Fax:
Mailing address:
  • Phone: 610-954-6048
  • Fax: 610-954-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD440531
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: