Provider Demographics
NPI:1912153222
Name:PATIL, SANDEEP MALLANAGOUDA (MD)
Entity type:Individual
Prefix:
First Name:SANDEEP
Middle Name:MALLANAGOUDA
Last Name:PATIL
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 1:2040 S ALMA SCHOOL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-7076
Mailing Address - Country:US
Mailing Address - Phone:480-290-1822
Mailing Address - Fax:949-864-3908
Practice Address - Street 1:1910 S STAPLEY DR STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6676
Practice Address - Country:US
Practice Address - Phone:602-525-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50371207RN0300X
LA202074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030611Medicaid
LA1893846Medicaid
LA4M225F600Medicare PIN
AZZ177702Medicare PIN
AZZ177704Medicare PIN