Provider Demographics
NPI:1760707509
Name:SANDBERG, LARS JOHAN MARCUS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARS JOHAN
Middle Name:MARCUS
Last Name:SANDBERG
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 1:770 E PROVIDENCE RD
Mailing Address - Street 2:APT A 401
Mailing Address - City:ALDAN
Mailing Address - State:PA
Mailing Address - Zip Code:19018-4318
Mailing Address - Country:US
Mailing Address - Phone:610-675-4558
Mailing Address - Fax:
Practice Address - Street 1:1500 LANSDOWNE AVE
Practice Address - Street 2:MEZZANINE FLOOR
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1200
Practice Address - Country:US
Practice Address - Phone:610-675-4558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT187160208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery