Provider Demographics
NPI:1164527206
Name:SANDINE, KURT (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:SANDINE
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 1:823 MCCORMICK ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1738
Mailing Address - Country:US
Mailing Address - Phone:360-866-6868
Mailing Address - Fax:
Practice Address - Street 1:3928 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1109
Practice Address - Country:US
Practice Address - Phone:360-455-1350
Practice Address - Fax:360-455-5354
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I26818Medicare UPIN