Healthcare Provider Details

I. General information

NPI: 1558461756
Provider Name (Legal Business Name): SANDRA STAUBLIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4288 3 MILE ROAD
WALKER MI
49534
US

IV. Provider business mailing address

4288 THREE MILE ROAD
WALKER MI
49534
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-3677
  • Fax: 616-459-6850
Mailing address:
  • Phone: 616-458-3677
  • Fax: 616-459-6850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301057826
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: