Provider Demographics
NPI:1104864826
Name:SAND LAKE MEDICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:SAND LAKE MEDICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:HUNT
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-345-1551
Mailing Address - Street 1:6200 METROWEST BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-7636
Mailing Address - Country:US
Mailing Address - Phone:407-345-1551
Mailing Address - Fax:407-345-4893
Practice Address - Street 1:6200 METROWEST BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-7636
Practice Address - Country:US
Practice Address - Phone:407-345-1551
Practice Address - Fax:407-345-4893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02942ZMedicare ID - Type UnspecifiedVICTOR HARDING, M.D.
FLD50687Medicare UPIN
FLS59133Medicare UPIN
FLK0617Medicare ID - Type UnspecifiedGROUP NUMBER
FLD50609Medicare UPIN
FLE4407VMedicare PIN