Healthcare Provider Details

I. General information

NPI: 1124015961
Provider Name (Legal Business Name): DAVID S. SANDOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 N PROSPECT AVE
MILWAUKEE WI
53211-4445
US

IV. Provider business mailing address

4425 N PORT WASHINGTON RD ATTN: CSMCP CLINIC CREDENTIALING
GLENDALE WI
53212-1082
US

V. Phone/Fax

Practice location:
  • Phone: 414-319-3000
  • Fax:
Mailing address:
  • Phone: 414-319-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number37739
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD492828
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: