Provider Demographics
NPI:1235151572
Name:IANNOTTI, SANDRA JOAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JOAN
Last Name:IANNOTTI
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 1:48 ROUTE 25A
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1431
Mailing Address - Country:US
Mailing Address - Phone:631-863-1007
Mailing Address - Fax:631-862-3668
Practice Address - Street 1:309 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2844
Practice Address - Country:US
Practice Address - Phone:631-360-2200
Practice Address - Fax:631-360-1328
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222190-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY411F31OtherEMPIRE BC/BS
NY200041953Medicare PIN
NY414G085961Medicare PIN
NYH30075Medicare UPIN