Provider Demographics
NPI:1396315776
Name:BIRKEN, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BIRKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2707
Mailing Address - Country:US
Mailing Address - Phone:813-844-5682
Mailing Address - Fax:
Practice Address - Street 1:409 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2707
Practice Address - Country:US
Practice Address - Phone:813-844-5682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148240208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery