Provider Demographics
NPI:1104867050
Name:SANDRA P DESAI DPM
Entity Type:Organization
Organization Name:SANDRA P DESAI DPM
Other - Org Name:LEE PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOADVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-936-2454
Mailing Address - Street 1:12734 KENWOOD LN
Mailing Address - Street 2:SUITE 44
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5666
Mailing Address - Country:US
Mailing Address - Phone:239-936-2454
Mailing Address - Fax:239-936-1974
Practice Address - Street 1:12734 KENWOOD LN
Practice Address - Street 2:SUITE 44
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5666
Practice Address - Country:US
Practice Address - Phone:239-936-2454
Practice Address - Fax:239-936-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2833213E00000X
FLPO2882213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340439100Medicaid
FL340439100Medicaid
FLK5353Medicare PIN