Basic Information
| Provider Information | |||||||||
| NPI: | 1053394361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANFORD | ||||||||
| FirstName: | MARY BARBARA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 49153 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336460127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133868444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 E FLETCHER AVE | ||||||||
| Address2: | FLORIDA HOSPITAL, TAMPA | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136157200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | FLME0051123 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00088280 | 01 | RAILROAD MEDICARE | OTHER | 14627 | 01 | BC | OTHER | 271056100 | 05 | FL | MEDICAID |