Healthcare Provider Details

I. General information

NPI: 1972864627
Provider Name (Legal Business Name): SANDRA BOLTAX-STERN, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 ANSONIA ROAD
WOODBRIDGE CT
06525
US

IV. Provider business mailing address

78 ANSONIA ROAD
WOODBRIDGE CT
06525
US

V. Phone/Fax

Practice location:
  • Phone: 203-387-3403
  • Fax: 203-387-9125
Mailing address:
  • Phone: 203-387-3403
  • Fax: 203-387-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number000011608
License Number StateCT

VIII. Authorized Official

Name: MRS. SANDRA P BOLTAX-STERN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-387-3403