Provider Demographics
NPI:1104812544
Name:SPEDALE, SANDRA L (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:SPEDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL CENTER BLVD
Mailing Address - Street 2:ATTN: HEIDI GWINN
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3147
Mailing Address - Country:US
Mailing Address - Phone:504-349-1297
Mailing Address - Fax:504-349-1146
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S850
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6450
Practice Address - Fax:504-349-6454
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA022008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1678562Medicaid
LAG32343Medicare UPIN
LA5W956Medicare ID - Type Unspecified