Active NPI
Sandeep Thota
- Dentist
- Bloomington, IL
National Provider Identifier
1467835223
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12012339A
- Practice address
- 1407 N Veterans Pkwy
Bloomington, IL 61704-6630 - Phone
- (314) 651-6550
- NPI assigned
- Jun 29, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 12012339A | IN | Primary |
Addresses
Primary practice location
1407 N Veterans Pkwy
Bloomington, IL 61704-6630
Mailing address
1407 N Veterans Pkwy
Bloomington, IL 61704-6630
Phone (314) 651-6550
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160613000808 | IL | Order and Referring Only - Dentist | 3678863131 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12012339A | IN | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1435536000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1435536000000",
"number": "1467835223",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1407 N VETERANS PKWY",
"city": "BLOOMINGTON",
"state": "IL",
"postal_code": "617046630",
"telephone_number": "314-651-6550"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1407 N VETERANS PKWY",
"city": "BLOOMINGTON",
"state": "IL",
"postal_code": "617046630",
"telephone_number": "314-651-6550"
}
],
"practiceLocations": [],
"basic": {
"last_name": "THOTA",
"first_name": "SANDEEP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-06-29",
"last_updated": "2015-06-29",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IN",
"license": "12012339A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bloomington, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.