Provider Demographics
NPI:1316942238
Name:GARG, SANDEEP (MD)
Entity type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:
Last Name:GARG
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 1:847 NE 19TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:STE 420
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5712
Practice Address - Country:US
Practice Address - Phone:503-692-0405
Practice Address - Fax:503-692-7978
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20499174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022549Medicaid
OR804330006OtherBLUE CROSS BLUE SHIELD
OR150287Medicaid
OR102677Medicare ID - Type Unspecified
OR150287Medicaid