Provider Demographics
NPI:1902871163
Name:GORDON-KOLB, SANDRA W (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:W
Last Name:GORDON-KOLB
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 1:10708 N ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-8533
Mailing Address - Country:US
Mailing Address - Phone:262-242-9413
Mailing Address - Fax:
Practice Address - Street 1:3237 S. 16TH ST.
Practice Address - Street 2:ST. FRANCIS HOSPITAL, 6TH FLOOR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-647-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47304-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIC65068Medicare UPIN