Provider Demographics
NPI:1033203633
Name:SANGE, SALLY HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:HARRIS
Last Name:SANGE
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 1:210 N GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3444
Mailing Address - Country:US
Mailing Address - Phone:321-452-7878
Mailing Address - Fax:321-452-7311
Practice Address - Street 1:210 N GROVE STREET
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3444
Practice Address - Country:US
Practice Address - Phone:321-452-7878
Practice Address - Fax:321-452-7311
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57788207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10809Medicare ID - Type Unspecified
E58545Medicare UPIN