Provider Demographics
NPI:1972583029
Name:SANDSTROM, TODD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ALAN
Last Name:SANDSTROM
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 1:14420 W MEEKER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5286
Mailing Address - Country:US
Mailing Address - Phone:623-975-8960
Mailing Address - Fax:623-975-8959
Practice Address - Street 1:14420 W MEEKER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5286
Practice Address - Country:US
Practice Address - Phone:623-975-8960
Practice Address - Fax:623-975-8959
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37740208600000X
AZ43169208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32236700Medicaid
AZ518209Medicaid
AZZ137624Medicare PIN
WI000168776Medicare PIN
WI32236700Medicaid