Healthcare Provider Details

I. General information

NPI: 1245495365
Provider Name (Legal Business Name): NATASHA AGNES SANDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8890 CENTRE PARK DRIVE SUITE 300B
COLUMBIA MD
21045-2104
US

IV. Provider business mailing address

2710 GOODWOOD RD
BALTIMORE MD
21214-2109
US

V. Phone/Fax

Practice location:
  • Phone: 410-696-7553
  • Fax:
Mailing address:
  • Phone: 410-696-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0071050
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number263711
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number263711
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0071050
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08428600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: