Healthcare Provider Details

I. General information

NPI: 1275828162
Provider Name (Legal Business Name): SANYOGEETA MUKUND BHAWAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-8307
  • Fax:
Mailing address:
  • Phone: 707-303-8307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT199514
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA126974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: