Provider Demographics
NPI:1043269228
Name:POPHAM, SANDY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDY
Middle Name:
Last Name:POPHAM
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 1:1001 E SUPERIOR ST STE L201
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-7980
Mailing Address - Fax:218-249-7911
Practice Address - Street 1:1001 E SUPERIOR ST STE L201
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2207
Practice Address - Country:US
Practice Address - Phone:218-249-7980
Practice Address - Fax:218-249-7911
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35304174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3100318OtherMEDICA
MN476323800Medicaid
WI32439700Medicaid
MN04N96P0OtherBLUE CROSS BLUE SHIELD
MNG69903Medicare UPIN
MN390000362Medicare ID - Type Unspecified
MN3100318OtherMEDICA