Provider Demographics
NPI:1124013479
Name:SANDIFER, DARRELL B (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:B
Last Name:SANDIFER
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 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-212-3890
Mailing Address - Fax:318-212-3888
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 600
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3890
Practice Address - Fax:318-212-3889
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020176207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1939331Medicaid
LA5R146CV71Medicare PIN
LA5R146Medicare PIN
LA1939331Medicaid