Basic Information
| Provider Information | |||||||||
| NPI: | 1114985942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESCANDON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 633 RTE 37 W | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087558007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322404787 | ||||||||
| FaxNumber: | 7322403114 | ||||||||
| Practice Location | |||||||||
| Address1: | 633 RTE 37 W | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087558007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322404787 | ||||||||
| FaxNumber: | 7322403114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 174400000X | 25MA04195700 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 6533507 | 05 | NJ | MEDICAID | 519171 | 01 | NJ | AETNA | OTHER |