Provider Demographics
NPI:1184654733
Name:SANDERSON, JAMES R (O D)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9924 W 143RD PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2404
Mailing Address - Country:US
Mailing Address - Phone:708-349-7571
Mailing Address - Fax:708-460-9355
Practice Address - Street 1:9924 W 143RD PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2404
Practice Address - Country:US
Practice Address - Phone:708-349-7571
Practice Address - Fax:708-460-9355
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36704Medicare UPIN
IL0239810001Medicare NSC
IL509770Medicare PIN