Basic Information
| Provider Information | |||||||||
| NPI: | 1922269661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDEEP | ||||||||
| FirstName: | NEFTHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 S J ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533964868 | ||||||||
| FaxNumber: | 2533964870 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 S J ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533964868 | ||||||||
| FaxNumber: | 2533964870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | A138843 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | MD60675977 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 2068250 | 05 | WA | MEDICAID |