Healthcare Provider Details

I. General information

NPI: 1649463662
Provider Name (Legal Business Name): SUNNY SUNDEEP SANDHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 KINGSLEY AVE
ORANGE PARK FL
32073-4593
US

IV. Provider business mailing address

1560 KINGSLEY AVE
ORANGE PARK FL
32073-4593
US

V. Phone/Fax

Practice location:
  • Phone: 904-458-7246
  • Fax: 904-517-5072
Mailing address:
  • Phone: 904-264-0400
  • Fax: 904-264-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301090049
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number68184
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number68184
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number68184
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME113652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: