Provider Demographics
NPI:1023009974
Name:DELISTATHIS, SANDRA M (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:DELISTATHIS
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 1:8201 BURNING TREE RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-2908
Mailing Address - Country:US
Mailing Address - Phone:301-469-6263
Mailing Address - Fax:
Practice Address - Street 1:4701 SANGAMORE RD
Practice Address - Street 2:UNITE N270
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2508
Practice Address - Country:US
Practice Address - Phone:240-507-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
MD415096100Medicaid
DC132971Medicare PIN
014251I06Medicare ID - Type Unspecified