Provider Demographics
NPI:1235549601
Name:WONTAKAL, SANDEEP NAGARAJ (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:NAGARAJ
Last Name:WONTAKAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-1180
Practice Address - Fax:410-614-9556
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291355207ZP0007X, 207ZP0105X
MDD93757207ZP0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine