Provider Demographics
NPI:1477881829
Name:SANDRA DEE MD LLC
Entity Type:Organization
Organization Name:SANDRA DEE MD LLC
Other - Org Name:STAGES PEDIATRIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-917-0075
Mailing Address - Street 1:947 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8361
Mailing Address - Country:US
Mailing Address - Phone:386-917-0075
Mailing Address - Fax:386-917-0655
Practice Address - Street 1:947 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8361
Practice Address - Country:US
Practice Address - Phone:386-917-0075
Practice Address - Fax:386-917-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277419400Medicaid
FLME96074OtherSTATE LICENSE