Provider Demographics
NPI:1174635791
Name:ADDARI, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:ADDARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SCHOFIELD RD
Mailing Address - Street 2:BLDG 1179
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7577
Mailing Address - Country:US
Mailing Address - Phone:210-808-2411
Mailing Address - Fax:
Practice Address - Street 1:2465 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5049
Practice Address - Country:US
Practice Address - Phone:505-532-6061
Practice Address - Fax:505-532-6063
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM339700801Medicare PIN
NMI65649Medicare UPIN