Provider Demographics
NPI:1003923731
Name:BUCHANAN, SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2905
Mailing Address - Country:US
Mailing Address - Phone:386-767-5477
Mailing Address - Fax:386-767-5580
Practice Address - Street 1:1185 DUNLAWTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2905
Practice Address - Country:US
Practice Address - Phone:386-767-5477
Practice Address - Fax:386-767-5580
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME71541OtherSTATE MEDICAL LICENSE
FL43582OtherBCBS
FL255109800Medicaid
FLE0498ZMedicare PIN
FL43582OtherBCBS