Provider Demographics
NPI:1942227814
Name:SHRADER, SANDRA K (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:SHRADER
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 1:1700 W HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2615
Mailing Address - Country:US
Mailing Address - Phone:321-473-8989
Mailing Address - Fax:321-802-4656
Practice Address - Street 1:1700 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2615
Practice Address - Country:US
Practice Address - Phone:321-473-8989
Practice Address - Fax:321-802-4656
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78256207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHR503AMedicare UPIN
FL49224VMedicare PIN