Healthcare Provider Details

I. General information

NPI: 1407994288
Provider Name (Legal Business Name): SANJAY SARIKONDA RAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

PO BOX 511353
LOS ANGELES CA
90051-7908
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4800
  • Fax:
Mailing address:
  • Phone: 866-284-2771
  • Fax: 800-334-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA92683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: