MEDICARE: MINNINDER JIT SANDHU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	058324	GA
2	2084P0800X	Psychiatry Physician	0101259335	VA

General Provider Information

NPI Number	:	1801074950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINNINDER JIT SANDHU M.D.

Provider Business Mailing Address
First Line	:	8500 EXECUTIVE PARK AVE STE 202
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-2253
Country	:	US
Telephone Number	:	703-852-7020
Fax Number	:	703-289-4612

Provider Business Practice Location Address
First Line	:	8500 EXECUTIVE PARK AVE STE 202
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-2253
Country	:	US
Telephone Number	:	703-852-7020
Fax Number	:	703-289-4612

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/06/2022

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