Healthcare Provider Details

I. General information

NPI: 1881636462
Provider Name (Legal Business Name): SANDRA M FAKULT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 ORANGE PL #2100
ORANGE VILLAGE OH
44122-4478
US

IV. Provider business mailing address

PO BOX 74224
CLEVELAND OH
44194-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-896-1800
  • Fax: 216-896-1801
Mailing address:
  • Phone: 216-383-6480
  • Fax: 216-383-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD464316
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-069995
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: