Basic Information
| Provider Information | |||||||||
| NPI: | 1689689028 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SALLUSTIO | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 189948 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01985799 | 05 | NY | MEDICAID |