Provider Demographics
NPI:1184673584
Name:BAUCOM, SANDRA S (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:S
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1809 S CHURCH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-1861
Mailing Address - Country:US
Mailing Address - Phone:757-780-8400
Mailing Address - Fax:757-432-3279
Practice Address - Street 1:1809 S CHURCH ST STE 302
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-1861
Practice Address - Country:US
Practice Address - Phone:757-780-8400
Practice Address - Fax:757-432-3279
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-06-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101043663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006706631Medicaid
VA006706631Medicaid