Provider Demographics
NPI:1043307077
Name:MALLIN, SANFORD (MD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:
Last Name:MALLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2710
Mailing Address - Country:US
Mailing Address - Phone:718-356-3411
Mailing Address - Fax:718-356-6900
Practice Address - Street 1:107 NELSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2710
Practice Address - Country:US
Practice Address - Phone:718-356-3411
Practice Address - Fax:718-356-6900
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124625174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09129Medicare UPIN
NY359312Medicare PIN