Provider Demographics
NPI:1215972427
Name:BOISSEAU, SANDRA LINDSAY (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LINDSAY
Last Name:BOISSEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 S LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-2424
Mailing Address - Country:US
Mailing Address - Phone:804-222-7474
Mailing Address - Fax:804-222-0458
Practice Address - Street 1:4620 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2424
Practice Address - Country:US
Practice Address - Phone:804-222-7474
Practice Address - Fax:804-222-0458
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010199450Medicaid
VA4065057OtherAETNA LIFE
VA1426978OtherCIGNA
VA333717OtherANTHEM BSBS OF VA
VA45892OtherSENTARA
VA293614OtherMAMSI
VA79152OtherSOUTHERN HEALTH SERVICES
VA4065057OtherAETNA HMO