Provider Demographics
NPI:1033128681
Name:SANDERS, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HIGHWAY 51 UNIT A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4425
Mailing Address - Country:US
Mailing Address - Phone:601-790-7105
Mailing Address - Fax:601-790-7865
Practice Address - Street 1:201 HIGHWAY 51 UNIT A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-790-7105
Practice Address - Fax:601-790-7865
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0122353Medicaid
MS080003217Medicare ID - Type Unspecified
MSG95897Medicare UPIN
MS080003225Medicare ID - Type Unspecified
MS0122353Medicaid
MS080003223Medicare ID - Type Unspecified
MS080003218Medicare ID - Type Unspecified
MS080003220Medicare ID - Type Unspecified
MS080003226Medicare ID - Type Unspecified
MS080003126Medicare ID - Type Unspecified
MS080003224Medicare ID - Type Unspecified