Healthcare Provider Details

I. General information

NPI: 1063739100
Provider Name (Legal Business Name): ZACHARY W SANDBULTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROBINHOOD MEDICAL PLZ
WINSTON SALEM NC
27106
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-7950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2013-01052
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: