Healthcare Provider Details

I. General information

NPI: 1700801537
Provider Name (Legal Business Name): SANJAY V KAMATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 SOUTH MARINE CORPS DRIVE
TAMUNING GU
96913
US

IV. Provider business mailing address

P.O. BOX 6578
TAMUNING GU
96931-6578
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-5824
  • Fax: 671-647-3546
Mailing address:
  • Phone: 671-646-6956
  • Fax: 671-647-3546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number43301
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberCI0007946
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number056577
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: