Healthcare Provider Details

I. General information

NPI: 1649249699
Provider Name (Legal Business Name): SAJU SEBASTIAN EAPEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 FRANKLIN RD SW
ROANOKE VA
24016-5206
US

IV. Provider business mailing address

1505 FRANKLIN RD SW
ROANOKE VA
24016-5206
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-7331
  • Fax: 540-343-7349
Mailing address:
  • Phone: 540-343-7331
  • Fax: 540-343-7349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101231964
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: