Provider Demographics
NPI:1346237385
Name:MARDOLKAR, SANJAY (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:MARDOLKAR
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 1:4439 STATE ROUTE 159 STE G10
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7708
Mailing Address - Country:US
Mailing Address - Phone:740-779-4300
Mailing Address - Fax:740-779-4391
Practice Address - Street 1:4439 STATE ROUTE 159 STE G10
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7708
Practice Address - Country:US
Practice Address - Phone:740-779-4300
Practice Address - Fax:740-779-4391
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01700208000000X
WV199002080A0000X
OH350775872080A0000X
OH35.077587208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346237385Medicaid
SCNC2514Medicaid
OH2143040Medicaid
WV6700083000Medicaid
WV6700083000Medicaid
NCNCP589CMedicare PIN
NCNCP589BMedicare PIN
WV0893835Medicare PIN
WVH06362Medicare UPIN
NCNCP589EMedicare PIN
SCNC2514Medicaid