MEDICARE: DR. DONNA R. SANDIDGE 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	207R00000X	Internal Medicine Physician	220140	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	030004925	OTHER	NY	RR MEDICARE PIN
3	CC8362	OTHER	NY	RR MEDICARE GROUP

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
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770557209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONNA R. SANDIDGE M.D.

Provider Business Mailing Address
First Line	:	310 TAUGHANNOCK BLVD
Second Line	:	SUITE 310
City	:	ITHACA
State	:	NY
Zip	:	14850-3251
Country	:	US
Telephone Number	:	607-252-3590
Fax Number	:	607-252-3592

Provider Business Practice Location Address
First Line	:	310 TAUGHANNOCK BLVD
Second Line	:	SUITE 310
City	:	ITHACA
State	:	NY
Zip	:	14850-3251
Country	:	US
Telephone Number	:	607-252-3590
Fax Number	:	607-252-3592

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	01/12/2016

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Directions to “ DR. DONNA R. SANDIDGE M.D.” Practice Location

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