Provider Demographics
NPI:1073604609
Name:SANDERSON, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:SANDERSON
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1184 E 80 N
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2906
Practice Address - Country:US
Practice Address - Phone:801-763-3885
Practice Address - Fax:801-763-3887
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187115-12052082S0105X, 207XS0106X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107005288103OtherIHC
UT13-00081OtherUNITED HEALTHCARE
UT215832OtherALTIUS
UT54270OtherDMBA
UT870281028SANOtherEMIA
UT79371OtherPEHP
UT870281028000Medicaid
UTP00167990OtherPALMETTO
UT005502590Medicare ID - Type UnspecifiedMEDICARE
UTE88678Medicare UPIN