Provider Demographics
NPI:1992090955
Name:SAMBASIVAN, AJAI (MD)
Entity type:Individual
Prefix:
First Name:AJAI
Middle Name:
Last Name:SAMBASIVAN
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 1:6431 FANNIN ST # G550A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN SUITE 1700
Practice Address - Street 2:MEMORIAL HERMANN TMC ORTHOPEDICS
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-704-2200
Practice Address - Fax:713-700-0590
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6717208100000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362529501Medicaid
TX523288YKY3OtherMEDICARE INDIVIDUAL ID
TX362529501Medicaid