Provider Demographics
NPI:1063648699
Name:MOALLEM, SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:MOALLEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:MARIELA
Other - Last Name:SAFIRSZTEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:3241 WESTERN BRANCH BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5260
Practice Address - Country:US
Practice Address - Phone:757-967-8622
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101255459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program