Healthcare Provider Details

I. General information

NPI: 1902215759
Provider Name (Legal Business Name): SANKALP DWIVEDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 MIDWAY PL
MENASHA WI
54952-1165
US

IV. Provider business mailing address

1550 MIDWAY PL
MENASHA WI
54952-1165
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax:
Mailing address:
  • Phone: 920-738-2000
  • 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 TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number71749
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number71749
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: