Basic Information
| Provider Information | |||||||||
| NPI: | 1205079407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDO | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | PARK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARK | ||||||||
| OtherFirstName: | JANE | ||||||||
| OtherMiddleName: | HEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 5TH ST S | ||||||||
| Address2: | ALL CHILDREN'S SPECIALTY PHYSICIANS | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277673051 | ||||||||
| FaxNumber: | 7277674970 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 5TH ST S | ||||||||
| Address2: | ALL CHILDREN'S SPECIALTY PHYSICIANS | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277673051 | ||||||||
| FaxNumber: | 7277674970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2009 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | D73945 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | A130695 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME124323 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 056591100 | 05 | MD | MEDICAID |