Healthcare Provider Details

I. General information

NPI: 1215236963
Provider Name (Legal Business Name): SANDRA M NDIAYE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA J MIKULIN D.O.

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

IV. Provider business mailing address

1900 SILVER CROSS BLVD PEDIATRICS OFFICE #3116
NEW LENOX IL
60451-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-300-1100
  • Fax: 815-300-7049
Mailing address:
  • Phone: 815-300-1100
  • Fax: 815-300-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02007537A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036134339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: