=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609870328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAJA K SANDBERG M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2005
-----------------------------------------------------
Last Update Date | 05/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 963 BUTTE ST
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-0828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-244-3921
-----------------------------------------------------
Fax | 530-244-5639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 COLONIAL BLVD ATTN: PAYER CONTRACTING & RELATIONS DEPT.
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-7342
-----------------------------------------------------
Fax | 239-931-7385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202K00000X
-----------------------------------------------------
Taxonomy Name | Phlebology Physician
-----------------------------------------------------
License Number | 21303
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | C41523
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------