Provider Demographics
NPI:1225171804
Name:SANDVOS, CHARITY BETH (MD)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:BETH
Last Name:SANDVOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 ASTER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8390
Mailing Address - Country:US
Mailing Address - Phone:573-275-6119
Mailing Address - Fax:
Practice Address - Street 1:3014 BLATTNER DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6361
Practice Address - Country:US
Practice Address - Phone:573-290-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine