Healthcare Provider Details

I. General information

NPI: 1568531424
Provider Name (Legal Business Name): SANJAY SURY SASTRY M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BEVILLE RD
SOUTH DAYTONA FL
32119-1860
US

IV. Provider business mailing address

801 BEVILLE RD
SOUTH DAYTONA FL
32119-1860
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-2300
  • Fax: 386-756-1697
Mailing address:
  • Phone: 407-473-5525
  • Fax: 386-756-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME84820
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME 84820
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: