Provider Demographics
NPI:1417904236
Name:TRIPATHI, SANJAY P (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:P
Last Name:TRIPATHI
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-334-5081
Practice Address - Fax:812-334-5091
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01094033A208600000X, 208G00000X
KS04-32222208G00000X
CO54328208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300095094Medicaid
IN090540A30OtherMEDICARE PTAN