Healthcare Provider Details

I. General information

NPI: 1972277333
Provider Name (Legal Business Name): SANDRA DEE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 TOWN CENTER DR
ORANGE CITY FL
32763-8361
US

IV. Provider business mailing address

947 TOWN CENTER DR
ORANGE CITY FL
32763-8361
US

V. Phone/Fax

Practice location:
  • Phone: 386-917-0075
  • Fax: 386-917-0655
Mailing address:
  • Phone: 386-917-0075
  • Fax: 386-917-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOCELYN PUA
Title or Position: OFFICE MANAGER
Credential:
Phone: 856-577-6888