Provider Demographics
NPI:1720057946
Name:SQUIRES, SANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HIGH ST
Mailing Address - Street 2:40 PARK PLACE
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-1004
Mailing Address - Country:US
Mailing Address - Phone:973-579-8975
Mailing Address - Fax:973-579-8423
Practice Address - Street 1:175 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1004
Practice Address - Country:US
Practice Address - Phone:973-579-8975
Practice Address - Fax:973-579-8423
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO582912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5603005Medicaid
NJ442465Medicare ID - Type Unspecified
NJ5603005Medicaid