Basic Information
| Provider Information | |||||||||
| NPI: | 1972549343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOOBY-GORDON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ALBANY ST FL GROUND | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6174149201 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 MASSACHUSETTS AVE | ||||||||
| Address2: | CROSSTOWN 6C | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145951 | ||||||||
| FaxNumber: | 6174149201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0300X | 72762 | MA | N | 207R00000X | 72762 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110050735A | 05 | MA | MEDICAID |