Provider Demographics
NPI:1174615017
Name:JOHAR, SANDEEP KUMAR (DO)
Entity type:Individual
Prefix:
First Name:SANDEEP
Middle Name:KUMAR
Last Name:JOHAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CHASE PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3346
Mailing Address - Country:US
Mailing Address - Phone:203-755-6677
Mailing Address - Fax:203-755-7166
Practice Address - Street 1:500 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3346
Practice Address - Country:US
Practice Address - Phone:203-755-6677
Practice Address - Fax:203-755-7166
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049078207P00000X, 207PS0010X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001421800Medicaid
NY02838200Medicaid
NYRB4058-GRP 70008AMedicare PIN
NYRB4059-GRP:BA0017Medicare PIN
CL927ZMedicare PIN