Provider Demographics
NPI:1447296355
Name:SURATWALA, SANJEEV J (MD)
Entity type:Individual
Prefix:
First Name:SANJEEV
Middle Name:J
Last Name:SURATWALA
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 1:833 NORTHERN BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 NORTHERN BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5315
Practice Address - Country:US
Practice Address - Phone:516-622-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243403207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447296355Medicaid
0603180002Medicare NSC
VA1447296355Medicaid