Provider Demographics
NPI:1316038847
Name:LAURENCIN, SANDRA B (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:B
Last Name:LAURENCIN
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:532 RIVERSIDE AVE STE 103
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4914
Practice Address - Country:US
Practice Address - Phone:904-353-5696
Practice Address - Fax:904-353-2844
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276321400Medicaid
FLU8798YMedicare PIN
I65172Medicare UPIN