MEDICARE: DR. DAVID CHARLES SAND M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01031985A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000595588	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1568577187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID CHARLES SAND M.D.

Provider Business Mailing Address
First Line	:	1900 CAREW ST.
Second Line	:	SUITE 1
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4765
Country	:	US
Telephone Number	:	260-373-9728
Fax Number	:	260-373-9740

Provider Business Practice Location Address
First Line	:	5104 N CLINTON ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5720
Country	:	US
Telephone Number	:	260-422-2481
Fax Number	:	260-969-3067

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	02/04/2009

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