Provider Demographics
NPI:1962825208
Name:SANDRA SHRADER, M.D. DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SANDRA SHRADER, M.D. DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-473-8989
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78256207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHR503AMedicare UPIN