Provider Demographics
NPI:1649463662
Name:SANDHU, SUNNY SUNDEEP (MD)
Entity type:Individual
Prefix:
First Name:SUNNY
Middle Name:SUNDEEP
Last Name:SANDHU
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 1:1560 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4593
Mailing Address - Country:US
Mailing Address - Phone:904-264-0400
Mailing Address - Fax:904-264-0401
Practice Address - Street 1:1560 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4593
Practice Address - Country:US
Practice Address - Phone:904-458-7246
Practice Address - Fax:904-517-5072
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090049207L00000X
GA68184208VP0014X, 208VP0000X, 2081P2900X
FLME113652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132784AMedicaid
GA202I725193Medicare PIN
FL003132784AMedicare UPIN
GA003132784AMedicaid
GA003132784CMedicaid
GA202I725193Medicare PIN
FL003132784AMedicare UPIN
GA003132784BMedicaid
GA003132784EMedicaid