Basic Information
| Provider Information | |||||||||
| NPI: | 1881636462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAKULT | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74224 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441940002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836480 | ||||||||
| FaxNumber: | 2163836745 | ||||||||
| Practice Location | |||||||||
| Address1: | 3909 ORANGE PL | ||||||||
| Address2: | #2100 | ||||||||
| City: | ORANGE VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168961800 | ||||||||
| FaxNumber: | 2168961801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 207R00000X | 35-069995 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2100032 | 05 | OH | MEDICAID |