Healthcare Provider Details

I. General information

NPI: 1790915973
Provider Name (Legal Business Name): DIVYAJOT SINGH SANDHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W 18TH ST STE 100
SIOUX FALLS SD
57104-4650
US

IV. Provider business mailing address

3801 COOPER DR E APT 112
COLUMBIA MO
65201-7105
US

V. Phone/Fax

Practice location:
  • Phone: 605-312-8500
  • Fax: 605-312-8501
Mailing address:
  • Phone: 317-640-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number10053
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: