Provider Demographics
NPI:1538112123
Name:ELLIOTT, SANDRA J (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:ELLIOTT
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 862851
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-2851
Mailing Address - Country:US
Mailing Address - Phone:954-847-4273
Mailing Address - Fax:954-847-4245
Practice Address - Street 1:601 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BCH
Practice Address - State:FL
Practice Address - Zip Code:33060
Practice Address - Country:US
Practice Address - Phone:954-786-5413
Practice Address - Fax:954-784-9249
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61256208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46299Medicare UPIN
FL45075Medicare ID - Type Unspecified