Provider Demographics
NPI:1134487903
Name:SANDU, MAMATHA (MD)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:SANDU
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 1:425 S HUNT CLUB BLVD STE 1051
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-2428
Mailing Address - Country:US
Mailing Address - Phone:407-786-4080
Mailing Address - Fax:407-786-4667
Practice Address - Street 1:425 S HUNT CLUB BLVD STE 1051
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-2428
Practice Address - Country:US
Practice Address - Phone:407-786-4080
Practice Address - Fax:407-786-4667
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112365208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116647100Medicaid