Provider Demographics
NPI:1083618052
Name:SANDERLIN, CHARLES W JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:SANDERLIN
Suffix:JR
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 1:3527 N VALDOSTA RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1068
Mailing Address - Country:US
Mailing Address - Phone:229-247-2290
Mailing Address - Fax:229-244-2626
Practice Address - Street 1:3527 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1068
Practice Address - Country:US
Practice Address - Phone:229-247-2290
Practice Address - Fax:229-244-2626
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051543207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265002900Medicaid
GAGRP1215OtherMEDICARE PTAN
GA00954445AMedicaid
20BBFMJMedicare ID - Type Unspecified
0367170001Medicare NSC
GAGRP1215OtherMEDICARE PTAN