Provider Demographics
NPI:1407802150
Name:SANDSTROM, PAUL E (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:SANDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16649 CANTLAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2806
Mailing Address - Country:US
Mailing Address - Phone:206-794-5767
Mailing Address - Fax:
Practice Address - Street 1:12710 TOTEM LAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2907
Practice Address - Country:US
Practice Address - Phone:425-821-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A05550Medicare UPIN