Provider Demographics
NPI:1801801501
Name:SANFORD MEDICAL GROUP, PA
Entity type:Organization
Organization Name:SANFORD MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINAY
Authorized Official - Middle Name:CHANDRA
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-322-4431
Mailing Address - Street 1:1621 W 1ST ST
Mailing Address - Street 2:P.O. BOX 848
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32772-0848
Mailing Address - Country:US
Mailing Address - Phone:407-322-4431
Mailing Address - Fax:407-322-4448
Practice Address - Street 1:1621 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1617
Practice Address - Country:US
Practice Address - Phone:407-322-4431
Practice Address - Fax:407-322-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93082207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG57586Medicare UPIN