Healthcare Provider Details

I. General information

NPI: 1851356182
Provider Name (Legal Business Name): MARK J. SANDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-5400
  • Fax: 631-444-7538
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number235234
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: