Provider Demographics
NPI:1235136078
Name:KNUDSEN, SANDRA J (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:KNUDSEN
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 1:826 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2321
Mailing Address - Country:US
Mailing Address - Phone:215-855-1054
Mailing Address - Fax:215-855-3706
Practice Address - Street 1:826 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446
Practice Address - Country:US
Practice Address - Phone:215-855-1054
Practice Address - Fax:215-855-3706
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 425461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA090396GWNMedicare PIN
PAI28382Medicare UPIN