Healthcare Provider Details

I. General information

NPI: 1699332932
Provider Name (Legal Business Name): SANJAY PRAKASH RAU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date: 05/23/2019
Reactivation Date: 06/10/2019

III. Provider practice location address

22-18 BROADWAY
FAIR LAWN NJ
07410-3016
US

IV. Provider business mailing address

22-18 BROADWAY
FAIR LAWN NJ
07410-3016
US

V. Phone/Fax

Practice location:
  • Phone: 201-475-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number280722
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB13016300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number281066
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: