Provider Demographics
NPI:1073611190
Name:SANDS, BRUCE E (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:SANDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11588 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-4521
Mailing Address - Country:US
Mailing Address - Phone:847-436-0270
Mailing Address - Fax:262-948-3536
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-4023
Practice Address - Fax:847-360-4221
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07785Medicare PIN
C42960Medicare UPIN