Healthcare Provider Details

I. General information

NPI: 1215014899
Provider Name (Legal Business Name): SANDRA WULACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MILLBURN AVE SUITE 6
SPRINGFIELD NJ
07081-1039
US

IV. Provider business mailing address

28 MILLBURN AVE SUITE 6
SPRINGFIELD NJ
07081-1039
US

V. Phone/Fax

Practice location:
  • Phone: 973-467-1773
  • Fax: 973-763-2088
Mailing address:
  • Phone: 973-467-1773
  • Fax: 973-763-2088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA04546200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: