Provider Demographics
NPI:1043315575
Name:SANDOUK, ADEL (MD)
Entity type:Individual
Prefix:
First Name:ADEL
Middle Name:
Last Name:SANDOUK
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:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-0122
Mailing Address - Country:US
Mailing Address - Phone:626-914-2900
Mailing Address - Fax:
Practice Address - Street 1:210 S GRAND AVE STE 307
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4278
Practice Address - Country:US
Practice Address - Phone:626-914-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86608207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31609Medicare UPIN
CAA86608Medicare PIN