Healthcare Provider Details

I. General information

NPI: 1669450458
Provider Name (Legal Business Name): SANDEEP KUMAR TIWARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/07/2023
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 BECKER DR
ROANOKE RAPIDS NC
27870-3303
US

IV. Provider business mailing address

529 BECKER DR
ROANOKE RAPIDS NC
27870-3303
US

V. Phone/Fax

Practice location:
  • Phone: 252-537-6465
  • Fax: 252-535-0951
Mailing address:
  • Phone: 252-537-6465
  • Fax: 252-535-0951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2003-00895
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: