Healthcare Provider Details

I. General information

NPI: 1083788509
Provider Name (Legal Business Name): SANJAY GHOSH PHD MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 CAROLINE DR STE 200
WASHINGTON MO
63090-4902
US

IV. Provider business mailing address

1080 CAROLINE DR STE 200
WASHINGTON MO
63090-4902
US

V. Phone/Fax

Practice location:
  • Phone: 636-390-2288
  • Fax: 636-390-2277
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberR6N94
License Number StateMO

VIII. Authorized Official

Name: SANJAY GHOSH
Title or Position: PHD MD PC
Credential:
Phone: 636-390-2288