Provider Demographics
NPI:1649231002
Name:SANDOR, JACQUELINE NAOMI (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:NAOMI
Last Name:SANDOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:J. NAOMI
Other - Middle Name:
Other - Last Name:SANDOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:50 N PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2666
Mailing Address - Country:US
Mailing Address - Phone:937-562-2280
Mailing Address - Fax:937-562-2282
Practice Address - Street 1:50 N PROGRESS DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2666
Practice Address - Country:US
Practice Address - Phone:937-562-2280
Practice Address - Fax:937-562-2282
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08101394Medicaid
OH2956547Medicaid
OHH163110Medicare PIN
MS080004281Medicare PIN
MSI60019Medicare UPIN