Healthcare Provider Details

I. General information

NPI: 1881756179
Provider Name (Legal Business Name): SANJAY R HEGDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 MAIN ST SUITE 206
WINCHESTER MA
01890-1961
US

IV. Provider business mailing address

955 MAIN ST STE 206
WINCHESTER MA
01890-4302
US

V. Phone/Fax

Practice location:
  • Phone: 781-729-5855
  • Fax: 781-721-5891
Mailing address:
  • Phone: 781-729-5855
  • Fax: 781-721-5891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMT183245
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD69588
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number247933
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: