Provider Demographics
NPI:1114999158
Name:SANDERS, STACEY (DPM)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 MIDDLE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-7107
Mailing Address - Country:US
Mailing Address - Phone:239-218-2051
Mailing Address - Fax:
Practice Address - Street 1:816 MIDDLE ST APT 1
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-7107
Practice Address - Country:US
Practice Address - Phone:239-218-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3875213EP1101X
FLPO3875213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
U76275Medicare UPIN
MD200P457GMedicare PIN
SDS106267Medicare PIN