Provider Demographics
NPI:1972864627
Name:SANDRA BOLTAX-STERN, MD, PC
Entity Type:Organization
Organization Name:SANDRA BOLTAX-STERN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOLTAX-STERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-387-3403
Mailing Address - Street 1:78 ANSONIA ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-387-3403
Mailing Address - Fax:203-387-9125
Practice Address - Street 1:78 ANSONIA ROAD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525
Practice Address - Country:US
Practice Address - Phone:203-387-3403
Practice Address - Fax:203-387-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000116082084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001116086Medicaid
CT260000231Medicare PIN