Basic Information
Provider Information | |||||||||
NPI: | 1457364234 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDA | ||||||||
FirstName: | ANIKA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 HAMILTON LNDG | ||||||||
Address2: | SUITE 100 | ||||||||
City: | NOVATO | ||||||||
State: | CA | ||||||||
PostalCode: | 949498256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4158841876 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 655 REDWOOD HWY FRONTAGE RD | ||||||||
Address2: | SUITE 216 | ||||||||
City: | MILL VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 949413034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4153833500 | ||||||||
FaxNumber: | 4153833554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 08/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A70742 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 00A707420 | 05 | CA |   | MEDICAID |