Provider Demographics
NPI:1285715938
Name:SHRESTHA, SANJIB (MD)
Entity type:Individual
Prefix:DR
First Name:SANJIB
Middle Name:
Last Name:SHRESTHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 ANNANDALE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7824
Mailing Address - Country:US
Mailing Address - Phone:601-420-0141
Mailing Address - Fax:
Practice Address - Street 1:827 ANNANDALE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7824
Practice Address - Country:US
Practice Address - Phone:601-420-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012153Medicaid
MSH11498Medicare UPIN
MS00012153Medicaid