Provider Demographics
NPI:1770594640
Name:SANDRA MADRID M D INC
Entity type:Organization
Organization Name:SANDRA MADRID M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-693-0725
Mailing Address - Street 1:12462 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1005
Mailing Address - Country:US
Mailing Address - Phone:562-693-0725
Mailing Address - Fax:562-693-2468
Practice Address - Street 1:12462 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1005
Practice Address - Country:US
Practice Address - Phone:562-693-0725
Practice Address - Fax:562-693-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41890208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G418900Medicaid
CAA48726Medicare UPIN
CA00G418900Medicaid