Provider Demographics
NPI:1205839560
Name:SANDEFUR, RICHARD M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:SANDEFUR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4199 GATEWAY BLVD
Mailing Address - Street 2:STE 2400
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8954
Mailing Address - Country:US
Mailing Address - Phone:812-858-4600
Mailing Address - Fax:812-858-4601
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:STE 2400
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8954
Practice Address - Country:US
Practice Address - Phone:812-858-4600
Practice Address - Fax:812-858-4601
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030934A207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100246580AMedicaid
D95040Medicare UPIN
IN100246580AMedicaid