Healthcare Provider Details

I. General information

NPI: 1992968853
Provider Name (Legal Business Name): SANDRA H BOLANOS MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 03/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 SW SAINT LUCIE WEST BLVD
PORT SAINT LUCIE FL
34986-2504
US

IV. Provider business mailing address

1730 SW SAINT LUCIE WEST BLVD
PORT SAINT LUCIE FL
34986-2504
US

V. Phone/Fax

Practice location:
  • Phone: 772-873-8155
  • Fax:
Mailing address:
  • Phone: 772-873-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number89982967
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116019794
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME137622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: