Provider Demographics
NPI:1154328193
Name:SANDERSON, JAMES GLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GLEN
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HUDSON CT
Mailing Address - Street 2:APARTMENT #3-B
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2135
Mailing Address - Country:US
Mailing Address - Phone:201-216-1505
Mailing Address - Fax:201-216-8803
Practice Address - Street 1:3 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-1824
Practice Address - Country:US
Practice Address - Phone:201-216-1505
Practice Address - Fax:201-216-8803
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07524000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0039217Medicaid
NJ083452Medicare ID - Type Unspecified
NJI21442Medicare UPIN