Healthcare Provider Details

I. General information

NPI: 1760665319
Provider Name (Legal Business Name): SUNANDA GHOSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUNANDA GHOSH MD

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax:
Mailing address:
  • Phone: 660-885-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10017554
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2010003235
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: