Healthcare Provider Details

I. General information

NPI: 1043269228
Provider Name (Legal Business Name): SANDY POPHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E SUPERIOR ST STE L201
DULUTH MN
55802-2207
US

IV. Provider business mailing address

1001 E SUPERIOR ST STE L201
DULUTH MN
55802-2207
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7980
  • Fax: 218-249-7911
Mailing address:
  • Phone: 218-249-7980
  • Fax: 218-249-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number35304
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35304
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: