Healthcare Provider Details

I. General information

NPI: 1255993689
Provider Name (Legal Business Name): SANJIVANI ASHOK SATHE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

PO BOX 26067
SALT LAKE CITY UT
84126-0067
US

V. Phone/Fax

Practice location:
  • Phone: 347-445-1567
  • Fax:
Mailing address:
  • Phone: 239-624-0400
  • Fax: 239-624-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.075191
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN35067
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2023-1012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: