Provider Demographics
NPI:1699332932
Name:RAU, SANJAY PRAKASH (DO)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:PRAKASH
Last Name:RAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10800 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-4200
Practice Address - Country:US
Practice Address - Phone:617-827-3596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2020-05-29
Deactivation Date:2019-05-23
Deactivation Code:
Reactivation Date:2019-06-10
Provider Licenses
StateLicense IDTaxonomies
MA280722207R00000X
MA281066207R00000X
PAOT020276390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine