Basic Information
Provider Information | |||||||||
NPI: | 1326067935 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SACKS | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5431 N UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 330674639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9543442522 | ||||||||
FaxNumber: | 9543449189 | ||||||||
Practice Location | |||||||||
Address1: | 1447 MEDICAL PARK BLVD | ||||||||
Address2: | SUITE 205 | ||||||||
City: | WELLINGTON | ||||||||
State: | FL | ||||||||
PostalCode: | 334143164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617982425 | ||||||||
FaxNumber: | 5617986356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 10/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | OS7360 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 252623900 | 05 | DC |   | MEDICAID |