Provider Demographics
NPI:1043204449
Name:SANDERS, KENTON (MD)
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:
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 1:1414 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7335
Mailing Address - Country:US
Mailing Address - Phone:910-796-7900
Mailing Address - Fax:
Practice Address - Street 1:1414 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7335
Practice Address - Country:US
Practice Address - Phone:910-796-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00256174400000X
NC200400256207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913632Medicaid
NC13632OtherBC/BS OF NC
NC8913632Medicaid
NC2025760AMedicare Oscar/Certification